SLIDE 1
12/16/2014 1
Andi Marmor, MD, MSEd UCSF Associate Professor, Pediatrics December, 2014
Nearly 20% of febrile infants
have “fever without a source” (FWS)
A few, although well-appearing, have an occult
bacterial infection:
UTI: Most common, simple to dx/treat SBI (bacteremia/meningitis): Harder to diagnosis,
worse to miss, decreasing in prevalence
Do all neonates need the full ROS workup? What counts as a fever “source”? If urine is +, do I need to do an LP? What is the role for labs – CBC, CRP, PCT? When and how should fever be treated? Rhizobium (“Rizzo”) is a 15 day old boy whose
mother reports that he felt warm today
The whole family has a cold, and Rizzo has
coughed a few times
VS: T 37.9 (R), P 145, R 35,
BP 70/40
Slightly fussy, but normal
exam, feeding well
SLIDE 2 12/16/2014 2
- A. Unreliable
- B. As accurate as a rectal temperature
- C. More sensitive than specific
- D. Usually due to over-bundling
U n r e l i a b l e A s a c c u r a t e a s a r e c t a l t . . . M
e s e n s i t i v e t h a n s p e c i f i c U s u a l l y d u e t
e r
u n d . . .
30% 15% 49% 6%
Parents better at ruling out
than ruling in
UTI/SBI more likely with
documented fever than with reported1
Vaccines? One time fever May occur 1-3 day later
1Yarden-Bilavsky, 2010
Icanhazcheeseburger.com
Neonates with FWS are at
high risk of bacterial infection
Occult infection: 15-20% ~90% of these are UTI’s Bacteremia with UTI is
common (10-15%)
Has the epidemiology of UTI/SBI in neonates
changed?
Greenhow et al, Epi of SBI in young infants. Pediatr Infect Dis J; 2014
2-3%
Better GBS screening?
13-18%
(92% of total)
<1%
SLIDE 3 12/16/2014 3
- A. S. pneumo, H. influenza, N. meningitidis
- B. E. Coli, S. pneumo, Group B Strep
- C. E. Coli, Group B Strep, Listeria
- D. E. Coli, Group B Strep, S. aureus
- E. Group B Strep, S. pneumo,
- H. influenza
- S. pneumo, H. influenza,...
- E. Coli, S. pneumo, Group..
- E. Coli, Group B Strep, Lis...
- E. Coli, Group B Strep, S....
Group B Strep, S. pneumo,
5% 20% 13% 35% 27% TABLE 3 . Bacterial Pathogens Detected in 129 Blood, 823 Urine and 16 CSF Cultures
Notice anything missing?
Greenhow et al, Pediatr Infect Dis J; 2014
- A. S. pneumo, H. influenza, N. meningitidis
- B. E. Coli, S. pneumo, Group B Strep
- C. E. Coli, Group B Strep, Listeria
- D. E. Coli, Group B Strep, S. aureus
- E. Group B Strep, S. pneumo, H. influenza
- E. Coli the most common cause of all types of
bacterial infections
Staph and enterococcus are emerging
pathogens
Listeria is no longer a major player Amp/Cefotaxime remains a good choice Cefotaxime for broad GP and GN coverage Amp for enterococcus (not listeria!)
SLIDE 4 12/16/2014 4
Clinical appearance, WBC: poor predictors
Greenhow et al, Pediatr Infect Dis J; 2014
Schwartz, 2009
- Risk of UTI/SBI decreases with age
- Reliability of ill appearance increases with age
UTI is the most common bacterial infection Ill appearance/low-risk criteria are not reliable
in neonates
- E. coli is the most common cause of ALL
UTI/SBI in neonates
GBS the major cause of non-UTI SBI Enterococcus, staph are emerging pathogens In general: collect urine, blood and CSF for
culture, and start broad-spectrum antibiotics
Ampicillin/cefotaxime
SLIDE 5 12/16/2014 5
Do all neonates need the full ROS workup? What counts as a fever “source”? If urine is +, do I need to do an LP? What is the role for labs – CBC, CRP, PCT? When and how should fever be treated? In general: collect urine, blood and CSF for
culture, and start broad-spectrum antibiotics
Ampicillin/cefotaxime Risk stratification/observation can be
considered in select circumstances
Multiple reassuring factors (eg: no documented
fever, + viral infection AND LRC met…)
You decide to get a CBC and blood culture, a
cath UA/culture and a rapid flu/RSV test
Results: WBC 15, with 33% neutrophils CRP is 1.2 mg/dL (normal) Rapid viral test positive for influenza Cath U/A negative
- 1. Start antibiotics, admit
- 2. LP, antibiotics, admit
- 3. No LP, no antibiotics, admit for observation
- vernight
- 4. Observe clinic/ED for 12 hours for fever
SLIDE 6 12/16/2014 6
- 1. Start antibiotics, admit
- 2. LP, antibiotics, admit
- 3. No LP, no antibiotics, admit for observation
- vernight
- 4. Observe clinic/ED for 12 hours for fever
All except #1 are OK
Rochalimea is a 7 week old girl with cough
and fever for 2 days at home
VS: T 38.9, P 150’s, R 30’s, O2 sat 100% On exam, she is well-appearing, lungs are
clear, she has slight crusting at the nares, no
UTI Common in girls and
uncircumcised boys (10- 15%)
SBI (1-2%)
- S. pneumo becomes the predominant pathogen
Significant decrease since S. pneumo vaccination Still a few cases of E. Coli, GBS, others Do all neonates need the full ROS workup? What counts as a fever “source”? If urine is +, do I need to do an LP? What is the role for labs – CBC, CRP, PCT? When and how should fever be treated?
SLIDE 7
12/16/2014 7
Focal bacterial infection (otitis
media, cellulitis)
Consider further W/U in neonates Named viral infection (bronchiolitis, croup)
OR + viral test
Infants < 3 months: still consider UTI Infants > 3 months: SBI/UTI unlikely Clear URI symptoms in infants > 3 mo of age Focal bacterial infection (otitis
media, cellulitis)
Consider further W/U in neonates Named viral infection (bronchiolitis, croup)
OR + viral test
Infants < 3 months: still consider UTI Infants > 3 months: SBI/UTI unlikely Clear URI symptoms in infants > 3 mo of age While her nonspecific URI symptoms don’t
constitute a clear source, you decide the most helpful initial test is a urinalysis.
Cath UA: 2+ for LE, + nitrites Due to her age, you decide to get a blood
culture and admit her for pyelo
Do you need to do an LP before starting abx? Do all neonates need the full ROS workup? What counts as a fever “source”? If urine is +, do I need to do an LP? What is the role for labs – CBC, CRP, PCT? When and how should fever be treated?
SLIDE 8
12/16/2014 8
Bacteremia is frequent in infants < 3 mo with
febrile UTI (10-15%)
However, meningitis with UTI is extremely
rare in well-appearing infants
A few cases of meningitis with UTI in well-
appearing neonates been reported
LP is not recommended routinely in infants >
1 mo if treating for pyelo
Paquette, 2011
Anaplasma, a 2 mo old boy, presents to the ED
with 2 days of tactile fever, no other symptoms
Unimmunized Circumcised T= 38.9, P 150, R 40’s, BP 90/65 Well-appearing, well-hydrated UA negative RVT negative for influenza/RSV Do all neonates need the full ROS workup? What counts as a fever “source”? If urine is +, do I need to do an LP? What is the role for labs – CBC, CRP, PCT? When and how should fever be treated?
SLIDE 9
12/16/2014 9
UTI: Urinalysis – 1 hr Meningitis: CSF cell
counts – 1 hr
Pneumonia: Clinical
diagnosis/CXR – 1 hr
Bacteremia: Blood
culture – 2 days!!!!
The only REALLY occult
SBI !
Andreola, 2007 Perfect test
Most useful in infants 1-3 mo of age (low-mod
risk) to R/O bacteremia
Best negative predictive value Does NOT reliably R/O UTI ( but we have
another test for that)
May have selective utility in otherwise low-
risk neonates
Only when it will change management… You send a CBC and CRP: WBC 16.7 (5-15), CRP 5.0 mg/dL (< 2) Next step? Tap, treat, admit
SLIDE 10 12/16/2014 10
Screen for UTI in all infants <3 mo with FWS If UA +, get blood culture and treat for UTI If UA negative consider RVT If UA and RVT neg, labs can help stratify risk of
SBI
LOW risk for SBI if ▪ WBC count 5-15K ▪ PCT < 0.2 ng/ml ▪ CRP <2.0 mg/dL Screen for UTI selectively
based on age/gender
Uncircumcised boys < 6 mo Girls < 24 mo, if fever > 48 hrs Otherwise, infants > 3 mo are at low risk for
Even unvaccinated infants are protected Empiric labs/antibiotics NOT recommended Do all neonates need the full ROS workup? What counts as a fever “source”? If urine is +, do I need to do an LP? What is the role for labs – CBC, CRP, PCT? When and how should fever be treated?
- A. Reduce discomfort/metabolic stress
- B. Reduce risk of seizures
- C. Document fever’s response to
antipyretics
- D. Decrease risk of brain damage
- E. Help the immune system fight
infection
R e d u c e d i s c
f
t / m e t a . . . R e d u c e r i s k
s e i z u r e s D
u m e n t f e v e r ’ s r e s p
. . D e c r e a s e r i s k
b r a i n d . . . H e l p t h e i m m u n e s y s t e m . . .
63% 28% 0% 3% 6%
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12/16/2014 11
Benefits of fever? Suggested in animal
studies, ICU pts
Dangers of fever? Discomfort, increased
metabolism, fluid loss
Fever phobia NOT febrile seizures < 50% of parents can define fever (> 38.5 C) 15-40 % think fever can cause brain damage,
seizure or death
Antipyretic dosing errors common Social/ethnic differences Latino parents: most concerned, prefer tactile AA parents: most likely to overdose antipyretics Lower level of education = higher fever concern
Cohee (2009), Poirier (2010)
Primary benefit is comfort In clinic: may make child easier to assess! Ibuprofen safe, well-tolerated and effective Use acetaminophen if ibuprofen contraindicated Alternating NOT recommended Sponging/cooling not effective and may cause
hypothermia
Do all neonates need the full ROS workup? What counts as a fever “source”? If urine is +, do I need to do an LP? What is the role for labs – CBC, CRP, PCT? When and how should fever be treated?
SLIDE 12
12/16/2014 12
Do all neonates need the full ROS workup? While SBI less common, ill appearance/low-risk
criteria still not reliable in neonates
Observation without antibiotics only in very select
circumstances (-UA, +RVT, well, etc)
What counts as a fever “source”? If urine is +, do I need to do an LP? What is the role for labs – CBC, CRP, PCT? When and how should fever be treated? Do all neonates need the full ROS workup? What counts as a fever “source”? In infants > 1 mo, named bacterial, viral illness OR
+ RVT can be considered a source
If urine is +, do I need to do an LP? What is the role for labs – CBC, CRP, PCT? When and how should fever be treated? Do all neonates need the full ROS workup? What counts as a fever “source”? If urine is +, do I need to do an LP? Not in a well-appearing infant > 1 month What is the role for labs – CBC, CRP, PCT? When and how should fever be treated? Do all neonates need the full ROS workup? What counts as a fever “source”? If urine is +, do I need to do an LP? What is the role for labs (CBC, CRP, PCT) Infants 1-3 mo, without viral source or UTI CRP/PCT more sensitive/specific than CBC When and how should fever be treated?
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Do all neonates need the full ROS workup? What counts as a fever “source”? If urine is +, do I need to do an LP? What is the role for labs – CBC, CRP, PCT? When and how should fever be treated? When child is uncomfortable/distressed Ibuprofen preferred Educate parents on treatment/supportive care!
Rhizobium Rochalimaea Anaplasma
