Andi Marmor, MD, MSEd UCSF Associate Professor, Pediatrics June, 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? What if LP attempts fail?
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
A. Unreliable B. As accurate as a rectal temperature C. More sensitive than specific D. Usually due to over-bundling
Parents better at ruling out than ruling in UTI/SBI more likely with documented fever than with reported 1 Vaccines? One time fever May occur 1-3 day later 1 Yarden-Bilavsky, 2010
Neonates with FWS have 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?
2-3% 13-18% Better GBS screening? 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
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!)
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
Ill appearance/low-risk criteria are not reliable in neonates UTI is the most common bacterial infection 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
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? What if LP attempts fail?
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 Rapid viral test positive for influenza Cath U/A negative What do YOU want to do?
1. LP, antibiotics, admit 2. No LP, no antibiotics, admit for observation overnight 3. Observe in ED for 12 hours for fever 4. NOT an OK option No LP AND start antibiotics/admit
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 other findings
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
A. Nasal wash for RSV B. Nasal wash for influenza C. Chest Xray D. CBC and blood culture E. Cath urine for UA and culture
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? What if LP attempts fail?
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
A. Nasal wash for RSV B. Nasal wash for influenza C. Chest Xray D. CBC and blood culture E. Cath urine for UA and culture
You obtain a cath urine sample on Rochalimea UA 2+ for LE, + nitrites You decide to get a blood culture and admit her for pyelo Do you need to do an LP before starting abx?
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? What if LP attempts fail?
UTI: Urinalysis Meningitis: CSF cell counts Pneumonia: Clinical diagnosis/CXR Bacteremia : Blood culture The only REALLY occult SBI ! Screening
Least abnormal Andreola, 2007 Most abnormal
Most useful in infants 1-3 mo of age Best for ruling OUT SBI in low-moderate risk infants 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 (< 3) Next step? You decide to get an LP before starting empiric antibiotics After 3 attempts, the parents refuse to let you continue What are your options?
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 of age Girls < 24 mo of age, if fever > 48 hrs Otherwise, infants > 3 mo are at low risk for occult SBI Even unvaccinated infants are protected Empiric labs/antibiotics NOT recommended
Neonates High risk of UTI/SBI, labs/clinical exam unreliable Generally should be tested/treated/admitted Infants 1-3 mo Test for UTI in all infants < 3 mo If viral source and/or normal serum inflammatory markers = reassuring against SBI Infants > 3 mo Selective testing for UTI only
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? What if LP attempts fail?
Anaplasma Rhizobium Rochalimea
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