Management of the Febrile Infant

Management of the Febrile Infant
Theodore C. Sectish, MD
Director, Residency Training Program in Pediatrics
Assistant Professor in Pediatrics
Stanford University School of Medicine

Fever in Infants
Learning Objectives:

* Fever in infants and outcomes of fever
* Evaluation of the febrile infant
* Modified Clinical Practice Guideline
* Guidelines and Practice
* New considerations
* Management of Fever without Source - 2001

Historical Perspective

* 1967 Occult bacteremia
* 1970s Hospitalization of febrile infants
* 1980s Outpatient management
* 1985 HIB Vaccine
* 1993 Clinical Practice Guideline
* 2000 PCV7 Vaccine
Fever in Practice

Diagnoses: Febrile Infants < 3 months

* URI 35.0%
* Otitis media 16.1%
* Bronchiolitis 8.4%
* Gastroenteritis 7.8%
* Urinary tract infection 4.7%
* Viral meningitis 2.7%
* Bacteremia 1.5%
* Bacterial meningitis 0.3%
* Cellulitis 0.2%
* Osteomyelitis 0.04%

Fever without Source (FWS)

* 20% of all infants <3 years with fever have FWS
* 3% have occult pneumococcal bacteremia
o Of bacteremic infants, 3% have meningitis
o 1 out of 1000!
* Risks of pneumococcal bacteremia in a PCV7 immunized infant is unknown
* Risk reduction estimate once immunized: 90%

Definition of Fever

* 38.00 C
* Rectal measurement
* Unbundled infant
* No recent antipyretics
* No recent immunizations

Bundling and Fever

* Experimental design with controls
* Bundling = 5 blankets and a hat
* 20 bundled infants: mean change + 0.560 C
* 20 infant controls: mean change - 0.040 C
* 2 infants reached 38.0 C, not higher

Febrile Infants: Outcomes of Interest
Serious Bacterial Infection (SBI)

* Urinary tract infection
* Sepsis or bacteremia
* Meningitis
* Bacterial enteritis
* Bone and joint infections
* Pneumonia
Probability of Bacterial Infection in Febrile Infants, <90 Days of Age
Probability of Occult Bacteremia: Febrile Infants, 3 - 36 months
Outcomes of Occult Bacteremia in the Age of Hemophilus
Occult Bacteremia in the Post-HIB Vaccine Era: 3-36 months
* Streptococcus pneumoniae 92%
* Others: 8%
o Salmonella sp
o N meningitidis
o Group A Streptococcus
o Group B Streptococcus
Outcomes of Outpatients with Pneumococcal Bacteremia

* 548 episodes in an ER population
* Treatment strategies varied:
o No antibiotics (N = 73)
o Oral antibiotics (N = 239)
o Parenteral antibiotics (N = 236)

Reevaluation of Outpatients with Pneumococcal Bacteremia
Conclusions
How Do Clinicians Evaluate Febrile Infants?
Evaluation of the Febrile Infant
* Careful history
* Physical examination
* Selected laboratory tests

Evaluation of the Febrile Infant

* Age
* Toxicity
* Decisions to test, to treat, to admit
* Evaluate:
o Vital signs
o Skin color
o Behavior
o State of hydration
* Document carefully and convey a clear picture of the overall clinical appearance of the patient.
* Perform a complete physical exam with particular attention to:
o Skin: for petechiae / purpura, rashes
o Oropharynx: for signs of gingivostomatitis/herpangina
o Pulmonary examination: for occult pneumonia
o Bones, joints and soft tissues: for infection
* Consider the history of fever as correct in all reported measured temperatures

What is “Toxic”?
It is a very difficult task to define “toxic”; the closest I can come to a definition is to say that if to an experienced physician he looks and acts damned sick, he’s toxic.

Definition: “Toxic” Infant
* Lethargy
o poor or absent eye contact
o failure to recognize parents
o poor interaction with persons / environment
* Signs of poor perfusion
* Marked hypoventilation / apnea
* Hyperventilation
* Cyanosis

1993 Clinical Practice Guideline
* Review of literature
* Evidence based
* Outcomes driven
* Consensus opinion

Important Clinical Questions

* Which young infants are at low risk for serious bacterial infection?
* Which older infants deserve empiric antibiotic therapy?

Clinical Practice Guideline
Low Risk Criteria: Clinical Appearance

* Nontoxic appearance
* Previously healthy
* No focal bacterial infection on exam
Otitis media is not considered a focal infection

Clinical Practice Guideline Low Risk Criteria: Laboratory Tests
Guideline: 0 - 28 days
Guideline: 29 - 90 days
Follow-up
Modified Guideline: 3 - 36 months
Modifications to the Guideline
Modified Guideline: 3 - 36 months Options

* Urinalysis or Urine leukocyte esterase + nitrite
* Send urine culture:
o All males <6 months + uncircumcised males <1yr
o Females <1 yr
* Send urine culture if positive urine screening
o Circumcised males 6-12 months
o Females 1-2 yrs

Modified Guideline: 3 - 36 months Options
Follow-up
Guidelines and Practice
Data Support Departures from the Guideline
Adherence Rates with Guideline
Otitis Media Influences Management
Data from Pediatric Practice:the PROS Fever Study
PROS Fever Study: Laboratory Tests
PROS Fever Study: Management
Adherence Rates to Guideline
New Considerations

* Automated Blood Culture Systems
* Band counts - out?
* Importance of UTI
* Fever with Source
o Recognizable Viral Syndromes
Automated Blood Culture Systems
Band Count: Not Discriminatory
Importance of UTI
Recognizable Viral Syndromes
Why Do Clinicians not Adhere to the Clinical Practice Guideline?
Many clinicians disagree with:

* Definition of fever
* Age thresholds
* Applying study data to their practices in which there is better compliance and follow-up
Caveat
Management of Fever Without Source

* Guideline is a place to start
* Need to know IZ status
* UTI: most frequent infection
* Recognize the “toxic” infant
* If you treat, obtain cultures
* Document carefully
* Arrange follow-up
Charles Prober’s Golden Rules

* The younger the infant, the greater the uncertainty
* A toxic appearance demands immediate action
* A non-toxic appearance fuels controversy
* Careful follow-up must be assured
* Recommendations continue to evolve
* No rules are golden

Management of the Febrile Infant.ppt