Fever without source
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This document discusses the clinical presentation and management of fever without source in children under 3 years old. It presents the case of a 4 month old male infant presenting with 3 days of fever. It reviews the child's history, examination findings, and discusses the appropriate evaluation and management for fever without source depending on the child's age, which may include blood cultures, urine analysis and cultures, lumbar puncture and antibiotics. The goal is to identify any serious bacterial infections while avoiding unnecessary testing and treatment.
Fever without source
- 1. Dr. Saptharishi L G Junior Resident
- 2. LEARNING OBJECTIVES Approach to a < 36 month old child with acute fever (fever< 5 days) Concept of ‘Fever Without Source’ and the related practical issues Clinical practice protocols for Fever Without Source (FWS) in <3 year olds
- 3. INDEX CASE B/o S 4 month old male infant Resident of Sec 38, Chandigarh Brought with complaints of Fever 3 days
- 4. History Of Presenting illness FEVER : Moderate to high grade, intermittent Documented up to a max of 102 F (by a local doctor) h/o excessive crying a/w poor feeding – with fever spike At other times, infant is playful, active and feeding well. No h/o rigors, No diurnal variation No h/o rapid breathing/ retractions/ nasal flaring No h/o neck retractions/ bulging fontanelle/ vomiting No h/o loose stools/ altered bowel habits
- 5. Other aspects of History PAST HISTORY: Born by FTNVD at PGI; Birth weight – 3.1 Kg Uneventful antenatal and perinatal period No h/s/o birth asphyxia/ NNJ FAMILY HISTORY: First born; No significant family history Exclusively Breastfed since birth Immunized appropriately for age (including Hib)
- 6. Examination Anthropometry: Weight – 6.1 kg (3rd to 15th percentile – WHO charts) Length – 64 cm (50th centile – WHO charts) OFC – 42 cm ( 0 to 1 Z score – WHO charts) Vitals: Temp - 39° C HR – 122/min RR – 42/min BP – 78/50 mm Hg CFT – 2 s SpO2 – 98%
- 7. Examination No pallor/icterus/ cyanosis/ clubbing/ LAP/ edema General impression Active, alert but crying ‘NOT- TOXIC/ SICK ‘ looking Head to toe examination No obvious focus of sepsis (cellulitis/ abscess/ furuncle) AF – at level, soft; Perianal region – WNL Ear – No e/o ASOM, Nose & Throat – mild congestion Systemic examination CVS/ RS – NAD P/A – Liver: palpable 2 cm under RCM, soft, non-tender CNS – Irritable but No e/o FND; Normal examination
- 8. So what would you like to do for this child?? Child with “just fever”, Sounds familiar? Because Almost all of us have „BURNT‟ our fingers !!!
- 9. FEVER Identified FWS / FWF focus Serious Benign Bacterial causes Infections
- 10. NORMAL TEMPERATURE RANGES Definition of fever Axillary 34.7° to 37.3° C (94.5 to 99.1 F) Oral 35.5° to 37.5° C (95.9 to 99.5 F) Rectal 36.6° to 37.9° C (97.9 to 100.2 F) Core body temperature > 38° C or 100.4 F Accurate temperature measurement – a must. Fever reported by parent, but now afebrile… Then ? Fever documented by axillary/ tympanic membrane Fever documented by rectal thermometry
- 11. Should doctors be worried as well? Risk of bacteremia in children with FWS Up to 10 % (old US data) 7% (BMJ 2010) Complications of Occult Bacteremia Delayed onset meningitis Pneumonia Septic arthritis Osteomyelitis Mortality
- 12. FEVER Can I somehow PICK-UP this group at Identified presentation?? FWS / FWF focus Serious Benign Bacterial causes Infections Occult Occult UTI Bacteremia Pneumonia
- 13. Height of fever No direct correlation with etiology Neonates Afebrile/hypothermic response despite SBI Older infants & children < 3 years old EXAGGERATED febrile response Temp > 40° C 38% risk of SBI High grade fever – unusual in older children/adolescents – SERIOUS Increasing prevalence of pneumococcal bacteremia with increasing temperatures
- 14. Pattern Of Fever DOES NOT reliably distinguish between etiologies Response to Anti-pyretic – Bacterial Vs. Viral
- 15. Observational Assessment Clinical appearance has good predictive value All children with toxic appearance must be hospitalized, evaluated and started on IV antibiotics
- 16. What constitutes ‘TOXIC’ look? Alertness – child looking at the observer, looking around the room, with eyes that are shiny & bright, etc. Normal motor ability – sitting without support, moving arms & legs on table or lap, etc. Playfulness – vocalizing spontaneously, playing with objects, reaching for objects, smiling & crying with noxious stimuli, etc. Irritability- consolability of cry Infant’s smile has a very high negative predictive value for meningitis
- 17. Interpretation Score – 10 2.7% SBI Yale Observation Score Score 11-15 26% SBI Score > 16 92.3% SBI 1 3 5 Quality of cry Strong or No cry Whimper or sob Weak cry / moan/ high pitched cry Reaction to Brief cry / content Cries off and on Persistent cry Parents State variation Awakens quickly Difficult to awaken No arousal/ falls asleep Color Pink Acrocyanotic Pale/ cyanotic /mottled Hydration Eyes, skin and Mouth slightly dry Mucosa , eyes – mucosa – moist dry/ sunken eyes Social Response Alert or smiles Alert/ brief smile No smile/ anxious/ dull
- 18.
- 19. BUT, Remember…. No combination of clinical history-taking & examination is good-enough
- 20. Age-based Clinical Practice Protocols < 28 days old 1-3 months old 3 – 36 months old
- 21. Neonates with FWS Highest risk group – 12% SBI – UTI/ Occult bacteremia Strep B, E coli, Listeria Highest sequelae Signs of viral illness – does not negate need for full diagnostic evaluation RSV infected neonates – same risk of SBI as RSV negative neonates All neonates with FWS should undergo • Blood c/s, Urinalysis, Urine c/s, CSF study, WBC count • CXR if respiratory symptoms/ Stool testing for WBC count if diarrhea present • IV antibiotics initiated as early as possible • Hospitalization and follow up
- 22. 1 – 3 month old with FWS ROCHESTER Criteria – LOW RISK group Appearing well Previously healthy No e/o skin/ soft tissue/ bone/ joint/ ear infections WBC count – 5000 to 15000/mm3 ANC < 1500/mm3 Urine WBC < 10 WBCs/HPF of centrifuged sample Fecal leucocyte count < 5/ HPF in children with diarrhea Boston criteria included routine CSF also (<10 WBC/HPF) Philadelphia criteria Criteria by Baker et al
- 23. 1 -3 month old with FWS Must Dos WBC counts / Urine dipstick / Urine & Blood c/s CSF Optional (depending on local protocol) LOW RISK Not LOW RISK F/u in 24 hrs Hospitalize No antibiotics IV antibiotics Collect cultures Collect cultures
- 24. 3 – 36 month old with FWS Fever definition stays… But for evaluation purpose, Temperature > 39° C CUT-OFF for further work-up Rationale: Risk of bacteremia – 0.8 % till 39° C Jumps to 8% beyond 39° C No significant further rise beyond 40 or 41° C
- 25. OCCULT OCCULT OCCULT UTI Pneumonia Bacteremia • IV Antibiotics • Hospitalize • CSF ( if not done already) • Blood c/s • Urine c/s • Urinalysis
- 26. American Family Physician 2007
- 27.
- 28. Rules of the Game Never do Lumbar Puncture in a child with FWS with suspected bacteremia, if you are not planning to give at least one dose of IV Antibiotic… Never start IV antibiotics to a <3 year-old child with FWS without CSF analysis*…
- 29. Emerging trends Effect of Pneumococcal and Hib vaccines Decrease in bacteremia in 3 – 36 months age group NEWER Recommendations Urinalysis more useful than CBC in this group Lee GM et al. Management of febrile children in the age of the conjugate pneumococcal vaccine: a cost-effectiveness analysis. Pediatrics 2001; 108: 835-44 Improving pneumococcal vaccine coverage Bacteremia rates < 0.5% STOP empirical testing and treatment
- 30. Caveats / Pitfalls Emphasis on detection of bacterial diseases… Useful for large tertiary care centers… Exclusion of certain sub-groups of children… Artificial chronological age distinctions… Majority assumed to be infectious… Useless unless based on local epidemiological data…
- 31. Role of newer markers C-Reactive protein Lacour et al sensitivity – 89%, specificity – 75% Andreola et al sensitivity – 88%, specificity – 61% Procalcitonin Lacour et al sensitivity – 93%, specificity – 78% Lopez et al CRP Vs. Pc – similar ROC AUC values
- 32. ‘TAKE- HOME’ MESSAGES Significant subset of febrile, 0 to 36 month old children ‘AT-RISK’ for Serious Bacterial Infections MORE So in Indian setting/ developing countries Higher bacteremia/ occult bacterial infections Even ‘ADEQUATE’ history & physical examination falls short…Misses SBI & over-treats benign illnesses Development of an INDIGENOUS data-based protocol – a necessity for every major tertiary care centre
- 33. ‘TAKE- HOME’ Practice points Febrile Neonate (0 to 28 days old) CBC, Blood c/s, urinalysis & urine c/s, CSF analysis, CXR*/Stool* Empiric IV antibiotic Hospitalize Febrile Young Infant (1-3 months) CBC, Blood c/s, Urinalysis and c/s, CXR*/Stool* Optional CSF# + IV/IM Ceftriaxone Hospitalize Follow-up as detailed OPD Vs. Admission
- 34. ‘TAKE- HOME’ Practice points Febrile child 3 – 36 months: Temp cut-off > 39° C Evaluate for occult infections (UTI/Bacteremia/Pneumonia) CBC with differential in children with fever > 39° C Indications for Urine c/s Boys Vs. girls CXR indications clinical / WBC > 20,000/mm3 Decision reg antibiotics & hospitalization
- 35. Primary Reference
- 36. Pediatrics 2011
- 37. THANK YOU ! Would be pleased to respond to queries… If any