12/16/2014 Nearly 20% of febrile infants have fever without a - PowerPoint PPT Presentation

12/16/2014 � 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 Andi Marmor, MD, MSEd UCSF Associate Professor, Pediatrics December, 2014 � Do all neonates need the full ROS workup? � Rhizobium (“Rizzo”) is a 15 day old boy whose � What counts as a fever “source”? mother reports that he felt warm today � If urine is +, do I need to do an LP? � The whole family has a cold, and Rizzo has � What is the role for labs – CBC, CRP, PCT? coughed a few times � When and how should fever be treated? � VS: T 37.9 (R), P 145, R 35, BP 70/40 � Slightly fussy, but normal exam, feeding well 1

12/16/2014 � Parents better at ruling out A. Unreliable than ruling in B. As accurate as a rectal temperature � UTI/SBI more likely with 49% documented fever than C. More sensitive than specific with reported 1 D. Usually due to over-bundling 30% � Vaccines? 15% � One time fever 6% � May occur 1-3 day later Icanhazcheeseburger.com e c b l i . f . a . i d . i . c l . e n e t p r l u n a s b U t n - c a r e e r h v t o a e s v o a t t i e i e s u t n a d r e 1 Yarden-Bilavsky, 2010 u s y c e l l c a a r u o s M s U A � Neonates with FWS are at high risk of bacterial 2-3% infection 13-18% � Occult infection: 15-20% (92% of Better GBS screening? total) � ~90% of these are UTI’s � Bacteremia with UTI is common (10-15%) <1% � Has the epidemiology of UTI/SBI in neonates changed? Greenhow et al, Epi of SBI in young infants. Pediatr Infect Dis J; 2014 2

12/16/2014 A. S. pneumo, H. influenza, N. meningitidis 35% B. E. Coli, S. pneumo, Group B Strep 27% C. E. Coli, Group B Strep, Listeria 20% D. E. Coli, Group B Strep, S. aureus 13% E. Group B Strep, S. pneumo, 5% H. influenza Group B Strep, S. pneumo, TABLE 3 . Bacterial Pathogens Detected in 129 Blood, 823 Urine and 16 CSF Cultures S. pneumo, H. influenza,... E. Coli, S. pneumo, Group.. E. Coli, Group B Strep, Lis... E. Coli, Group B Strep, S.... � Notice anything missing? Greenhow et al, Pediatr Infect Dis J; 2014 A. S. pneumo, H. influenza, N. meningitidis � E. Coli the most common cause of all types of B. E. Coli, S. pneumo, Group B Strep bacterial infections C. E. Coli, Group B Strep, Listeria � Staph and enterococcus are emerging D. E. Coli, Group B Strep, S. aureus pathogens E. Group B Strep, S. pneumo, H. influenza � 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!) 3

12/16/2014 Schwartz, 2009 � Clinical appearance, WBC: poor predictors • Risk of UTI/SBI decreases with age • Reliability of ill appearance increases with age Greenhow et al, Pediatr Infect Dis J; 2014 � UTI is the most common bacterial infection � In general: collect urine, blood and CSF for � Ill appearance/low-risk criteria are not reliable culture, and start broad-spectrum antibiotics in neonates � Ampicillin/cefotaxime � 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 4

12/16/2014 � Do all neonates need the full ROS workup? � In general: collect urine, blood and CSF for � What counts as a fever “source”? culture, and start broad-spectrum antibiotics � If urine is +, do I need to do an LP? � Ampicillin/cefotaxime � What is the role for labs – CBC, CRP, PCT? � Risk stratification/observation can be � When and how should fever be treated? 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 1. Start antibiotics, admit cath UA/culture and a rapid flu/RSV test 2. LP, antibiotics, admit � Results: 3. No LP, no antibiotics, admit for observation � WBC 15, with 33% neutrophils overnight � CRP is 1.2 mg/dL (normal) 4. Observe clinic/ED for 12 hours for fever � Rapid viral test positive for influenza � Cath U/A negative 5

12/16/2014 1. Start antibiotics, admit � Rochalimea is a 7 week old girl with cough 2. LP, antibiotics, admit and fever for 2 days at home 3. No LP, no antibiotics, admit for observation � VS: T 38.9, P 150’s, R 30’s, O2 sat 100% overnight � On exam, she is well-appearing, lungs are 4. Observe clinic/ED for 12 hours for fever clear, she has slight crusting at the nares, no other findings All except #1 are OK � UTI � Do all neonates need the full ROS workup? � Common in girls and � What counts as a fever “source”? uncircumcised boys (10- � If urine is +, do I need to do an LP? 15%) � What is the role for labs – CBC, CRP, PCT? � SBI (1-2%) � When and how should fever be treated? � S. pneumo becomes the predominant pathogen � Significant decrease since S. pneumo vaccination � Still a few cases of E. Coli, GBS, others 6

12/16/2014 � Focal bacterial infection (otitis � Focal bacterial infection (otitis media, cellulitis) media, cellulitis) � Consider further W/U in neonates � Consider further W/U in neonates � Named viral infection (bronchiolitis, croup) � Named viral infection (bronchiolitis, croup) OR + viral test OR + viral test � Infants < 3 months: still consider UTI � Infants < 3 months: still consider UTI � Infants > 3 months: SBI/UTI unlikely � Infants > 3 months: SBI/UTI unlikely � Clear URI symptoms in infants > 3 mo of age � Clear URI symptoms in infants > 3 mo of age � While her nonspecific URI symptoms don’t � Do all neonates need the full ROS workup? constitute a clear source, you decide the � What counts as a fever “source”? most helpful initial test is a urinalysis. � If urine is +, do I need to do an LP? � Cath UA: 2+ for LE, + nitrites � What is the role for labs – CBC, CRP, PCT? � Due to her age, you decide to get a blood � When and how should fever be treated? culture and admit her for pyelo � Do you need to do an LP before starting abx? 7

12/16/2014 � 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 � Do all neonates need the full ROS workup? with 2 days of tactile fever, no other symptoms � What counts as a fever “source”? � T= 38.9, P 150, R 40 ’ s, BP 90/65 � Unimmunized � If urine is +, do I need to do an LP? � Circumcised � What is the role for labs – CBC, CRP, PCT? � When and how should fever be treated? � Well-appearing, well-hydrated � UA negative � RVT negative for influenza/RSV 8

12/16/2014 Perfect test � 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 � You send a CBC and CRP: � Most useful in infants 1-3 mo of age (low-mod risk) to R/O bacteremia � WBC 16.7 (5-15), CRP 5.0 mg/dL (< 2) � Best negative predictive value � Next step? � Does NOT reliably R/O UTI ( but we have � Tap, treat, admit another test for that) � May have selective utility in otherwise low- risk neonates � Only when it will change management… 9

12/16/2014 � Screen for UTI in all infants <3 mo with FWS � Screen for UTI selectively based on age/gender � If UA +, get blood culture and treat for UTI � Uncircumcised boys < 6 mo � If UA negative consider RVT � If UA and RVT neg, labs can help stratify risk of � Girls < 24 mo, if fever > 48 hrs SBI � Otherwise, infants > 3 mo are at low risk for � LOW risk for SBI if occult SBI ▪ WBC count 5-15K � Even unvaccinated infants are protected ▪ PCT < 0.2 ng/ml � Empiric labs/antibiotics NOT recommended ▪ CRP <2.0 mg/dL � Do all neonates need the full ROS workup? A. Reduce discomfort/metabolic stress � What counts as a fever “source”? B. Reduce risk of seizures 63% � If urine is +, do I need to do an LP? C. Document fever’s response to � What is the role for labs – CBC, CRP, PCT? antipyretics 28% � When and how should fever be treated? D. Decrease risk of brain damage 6% 3% 0% E. Help the immune system fight s e . . . infection . r . . . n . a . u o . m z . t i p d e e e s n t m s e s a i y / f r o r s t s b r k r ’ e o f n f s e o m i v u r e k m o e f s c m c u t r i s n i d e i d e e e m s e R a h e c u t u r p c c d o l e e e D D H R 10