Fever: Your next Friend Request

(and why I love Philly sports!)

Robert P. Olympia, MD, FAAP

Department of Pediatrics & Emergency Medicine Penn State Hershey Childrens Hospital

August 24, 2011

Mommy Call 10 P.M.

You receive a call from a frantic mother who says that her 10 month old son spiked a fever of 105 tonight. He has had a runny nose for a couple days and low grade fevers to 99. He is eating well and wetting diapers normally. He is not breathing uncomfortably.

Mommy Call 10 P.M.

Mother has been alternating Tylenol and Motrin every 3 hours he seems to be happy when his fever comes down, but acting irritable when his fever is high. What is your advice to this mother?

Truth or Myth?
High fevers can cause brain damage High fevers can cause seizures High fevers mean that the infant or child has a severe bacterial infection A lack of response of a fever to Tylenol or Motrin means the infant or child has a severe bacterial infection

What is a fever?
Fever is your friend Age less than 24 months: > 100.4o C (rectally)
But do you really need a rectal temperature?

Age greater than 24 months: > 99.8o C (orally) Differential diagnosis:

Viral (most common) SBI: meningitis, pneumonia, UTI (most common SBI), bacteremia , osteomyelitis, septic arthritis,

What is your workup?

Lab tests
Blood, urine, stool, spinal tap

Radiological studies
X-ray or CT scan

Antibiotics
IV or IM or PO or none

Hospitalization versus discharge

Are you a test minimizer or risk minimizer ?

Case 1
6 week old former 36 week preemie born via C/S with tactile fever at home for 2 days and increase in spitting up In ED, infant is well appearing without respiratory distress Vitals: temp 101 (R), HR 176, RR 48, sat 96% on RA PE is unremarkable

Pearl: Actual versus Adjusted age

WHAT IS YOUR WORKUP?

What is your workup?

Lab tests
Blood, urine, stool, spinal tap

Radiological studies
X-ray or CT scan

Antibiotics
IV or IM or PO or none

Hospitalization versus discharge

Lets go Old School

The Boston Criteria The Rochester Criteria The Philadelphia Criteria

The Boston Criteria (1991)

Baskin, ORourke, Fleisher

28 to 89 days, temp > 38.0 , well appearing and no source detected Low risk criteria: CSF (< 10 WBC), UA (<10 WBC), CXR (no infiltrate), CBC (<20,000 WBC) 27/503 (5%) Low Risk with SBI
Bacteremia (8), bacteremia and UTI (1), UTI (8), bacteria GE (10)

The Rochester Criteria (1994)

Jaskiewicz, McCarthy, et al

< 60 days, temp > 38.0, well appearing and no source detected Low risk criteria: WBC (5 to 15,000), ABC (< 1500), UA (< 10 WBC), stool (<5 WBC) LP at the discretion of the physician Non low risk SBI : 61/494 (12.3%) Low risk SBI: 5/437 (1.1%)

The Philadelphia Criteria(1999)

Baker, Bell, Avner

29-56 days, temp >38.0, well appearing and no source detected Low risk criteria: CSF (<8 WBC), UA (<10 WBC), CXR (no infiltrate), CBC (<15,000 WBC), BNR (<0.2) 0/388 Low Risk with SBI 164/781 (21%) High Risk with SBI

So what do I do

Workup of infant 1-2 months

SBI: 10% Etiology: GBS, E. coli, S. pneumonia The Boston Criteria The Rochester Criteria The Philadelphia Criteria [WWOD] Workup is controversial RSV (+) or Influenza (+) workup different

How about the grey zone?

Hsiao AL, et al. Pediatrics 2006
Prospective study, 229 well appearing infants aged 2-6 months with fever > 38.0 Blood, urine, DFA nasal swabs for respiratory viruses 10.3% with SBI (41 UTI, 4 bacteremia) 38% had (+) DFA (RSV/Influenza A) LP performed in 58 infants (0% meningitis) WBC count (17.1K vs. 12.4 K) and CRP (2.6 vs. 0.9) were elevated in infants with SBI

WWOD 2 to 3 months fever without source

Pearl: Role for bagged urine

Pearl: Urine culture necessary?

Case 2
18 day old FT NSVD male newborn Fever at home of 101 (R) and mild nasal congestion In ED, newborn is well appearing with temp 100.3 (R) and normal vital signs PE is unremarkable except for mild nasal crusting Brother at home is sick with a cold

WHAT IS YOUR WORKUP?

What is your workup?

Lab tests
Blood, urine, stool, spinal tap

Radiological studies
X-ray or CT scan

Antibiotics
IV or IM or PO or none

Hospitalization versus discharge

Unpredictability of SBI in Febrile Infants < 1 month (Baker, 1999)

Prospective, 3 to 28 days, temp > 37.9 32/254 (12.6%) SBI 109/254 met criteria for Low Risk based on Philadelphia criteria 5/109 (4.6%) had SBI
UTI (2) Bacteremia (2) BGE (1)

Applying Protocols to Febrile Infants < 28 days (Kadish, 2000)

Retrospective application of Boston and Philadelphia criteria, age 1 to 29 days, temp > 37.9 45/372 (12%) with SBI Application of Low risk criteria
Boston: 8/231 (3.5%) with SBI Philadelphia: 6/186 (3.2%) with SBI

So what do I do

Summary
Age < 28 days SBI: 13% Etiology: GBS, E. coli, Enterococcus, Listeria monocytogenes Full sepsis workup Admission Ampicillin plus cefotaxime or gentamycin

Pearl: Effect of Prophylactic Antibiotic during delivery for GBS

Case 3
6 week old FT NSVD female presents with copious nasal discharge and fever to 102 for 3 days Vitals: temp 101.9 (R), HR 168, RR 56, sat 95% on RA PE: lungs with diffuse wheezing throughout but relatively good aeration bilaterally RSV rapid nasal wash is POSITIVE

WHAT IS YOUR WORKUP?

What is your workup?

Lab tests
Blood, urine, stool, spinal tap

Radiological studies
X-ray or CT scan

Antibiotics
IV or IM or PO or none

Hospitalization versus discharge

What is the evidence for RSV + and SBI?

Davies (1996)
0% SBI < 6 months

Antonow (1998)
1.8% SBI < 6 months

Liebelt (1999)
0% SBI < 3 months

Greenes (1999)
0.2% with bacteremia 3 to 36 months

RSV and SBI < 60 days

Levine et al (Pediatrics, 2004) Multicenter, prospective, < 60 days, temp > 38 N= 1248 [269 RSV (+)] 11.4% SBI overall
7% SBI if RSV (+) UTI 5.4%, bacteremia 1.1%, meningitis 0%

Therefore if RSV (+), may not need to do LP

Influenza and SBI < 60 days

Krief et al (Pediatrics, 2009) Multicenter, < 60 days, temp > 38 N= 844 [123 Influenza (+)] 11.3% SBI overall SBI (2.5% flu + vs. 13.3% flu -) UTI (2.5% flu + vs. 10.8% flu -) Bacteremia (0% flu + vs. 2.2% flu -) Meningitis (0% flu + vs. 0.9% flu -) Therefore if influenza (+) then just do urinalysis and urine culture

So what do I do

Pearl: Do you need CXR for fever and first time wheezing?

Pearl: Evaluation of fever post vaccination 6 to 12 weeks old?

Case 4
10 month old FT NSVD male presents with tactile fever for one day and no other symptoms 4 year old sibling with the flu In the ED, the child is crying but consolable, temperature 104.2 (R), HR 182, RR 60, sat 99% on RA PE is unremarkable

WHAT IS YOUR WORKUP?

What is your workup?

Lab tests
Blood, urine, stool, spinal tap

Radiological studies
X-ray or CT scan

Antibiotics
IV or IM or PO or none

Hospitalization versus discharge

Back in the day.

Consensus statement (Baraff et al, 1993) Obtain CBC on all Blood culture
Option 1: All with temp > 39.0 Option 2: temp > 39.0 and WBC > 15,000

Empiric antibiotics
Option 1: All with temp > 39.0 Option 2: temp > 39.0 and WBC > 15,000

Let me try to convince you

Post Hib vaccine era [1990]
Prevalence of all OB 1.6-1.9% (Probably now less than 1% according to experts) Pneumococcal OB 83-92% Spontaneous resolution SP 95.7% Rate of adverse outcome for SP 0.03% Vaccine provides protection against 83-85% of SP disease

Just an example to drive the point

You see 10,000 febrile infants 3 to 36 months without a source 170 infants (1.7%) with have bacteremia 148 (87%) will have SP (22 without SP) 141 (95.7%) resolve spontaneously Of the 7 infants without spontaneous resolution, less than 1 (0.03%) will go on to adverse outcome (meningitis or sepsis)

How about the others

Clinical and Hematologic Features do not reliably identify children with unsuspected meningococcal disease (Kupperman, 1999)
Retrospective cases of meningococcal disease initially evaluated and discharged to home No significant difference in the temperature, WBC, ANC between those children who had meningococcal disease and those who did not Therefore = unable to predict which children would go on to have meningococcal disease

How about the height of fever?

Lee, 1998 [Rates of bacteremia]
39-39.4: 39.5-39.9: 40.0-40.4: 40.5-40.9: > 41.0 0.9% (22/2389) 1.1% (30/2669) 1.7% (35/2096) 2.4% (29/1215) 2.8% (11/387)

Occult UTI
Shaw, 1998
914 febrile infants without a source Temp > 38.5, male < 1 year and female < 2 years Overall prevalence 3.3% Females: 4.3% (white 16.1%, non-white 2.5%) Males: 1.8% (white 2.6%, non-white 1.7%) Prevalence in uncircumcised males 8.0%

WWOD To Cath or Not to Cath

UA and culture if:
Female, < 2 years of age, > 2 days of fever , and no source Male, circumcised or uncircumcised, < 6 months, > 2 days of fever, and no source Male, only uncircumcised, 6-12 months, > 2 days of fever, and no source Thrown out the window if previous history of UTI or anatomical abnormality

Occult pneumonia
Bachur, 1999
Prospective, children < 5 years with fever > 39.0 and WBC > 20,000 38/146 (26%) had CXR consistent with pneumonia

Rothrock, 2001
Absence of 4 signs (respiratory distress, tachypnea, crackles, decreased BS) excludes pneumonia

WWOD CXR
Fever with respiratory distress and/or hypoxia Fever with wheezing if not responding to bronchodilators [possible secondary bacterial infection] Fever and worsening cough for > 2 days and no wheezing Fever and crackles or rales

Risk of Bacteremia Post H. influenza vaccine (Lee, 1998)

Prospective, well appearing 3 to 36 months with temp >39 presenting to ED 149/9465 (1.57%) bacteremia
92% SP, 5% Salmonella, 1% NM, 1% GAS, 1% GBS

ANC and WBC were similar and better than ABC and temperature for predicting occult bacteremia

Predictors of Occult Bacteremia (Kupperman, 1998)

Prospective well appearing 3 to 36 months with temp > 39 presenting to the ED 164/6579 (2.5%) with bacteremia Recommend:
age 2 to 3 years/temp < 39.5 - No W/U (1.1%) age 2 to 3/temp >39.5 or age 3 to 24 months/temp >39.0 - get ANC (2.6%) if ANC > 10,000 - blood culture and ABX (8.3%)

Are antibiotics useful to prevent serious sequelae?

Bulloch (1997)
PO or IM antibiotics did not reduce the risk of serious infection

Rothrock (1997)
Meta-analysis No evidence that oral or parental antibiotics reduce the risk of meningitis due to SP

Therefore no need to give antibiotics at all !

Workup of infant > 2 months

SBI: 10.3% (2-6 months), Bacteremia: 0.5-2% Etiology: S. pneumonia, N. meningitidis, S. aureus, GABHS, Salmonella Workup is controversial
WWOD: Blood and LP only if toxic appearing WWOD: Catheterized urine if Female < 2 years and fever > 2 days, if uncircumcised Male < 1 year and circumcised Male < 6 months

IM or PO Antibiotics should never be given to prevent SBI

Case 5
13 month old female, no PMH, presents via EMS for seizure Vomiting for 3 days and fever to 102 treated by mother with appropriate dose of acetaminophen 5 minute long generalized tonic clonic seizure In ED, infant sleepy but arousable, temp 104 (R) with tachycardia to 174 PE is unremarkable

WHAT IS YOUR WORKUP?

What is your workup?

Lab tests
Blood, urine, stool, spinal tap

Radiological studies
X-ray or CT scan

Antibiotics
IV or IM or PO or none

Hospitalization versus discharge

Simple Febrile Seizure

Age 5 months to 6 years of age Fever [not height of fever but rate of rise] Seizure
Generalized tonic clonic activity Less than 15 minutes duration No more than one seizure during a 24 hour time period No underlying CNS abnormality or development delay

AAP Practice Parameters (1996)

LP strongly considered less than 12 months or received prior antibiotic treatment To consider LP if 12 to 18 months If > 18 months, recommended in presence of meningeal signs or symptoms No routine EEG, blood studies, or neuroimaging if simple febrile seizure

Other studies Febrile seizures

Teach (1999)
retrospective, < 6 years 6/206 (2.9%) bacteremia (all SP), 1/130 (0.7%) UTI, 0/66 meningitis

Shah (2002)
retrospective, 2 to 24 months, N=379 8/379 (2.1%) bacteremia - 7 SP, 1 GAS no meningitis or adverse outcomes

Pearl: Work-up of a Febrile Seizure

Most important question: How was the infant or child acting before the seizure and how is the infant or child acting since the seizure? Work up the infant or child the same way you would if they did not have a seizure.

Case 6
2 year old male child presents with fever and rash for 2 days associated with vomiting and decreased activity In the ED, child appears dehydrated with obvious petechiae on face and trunk (15-20) PE: fever 101 (R), HR 156, RR 38, sat 97%, child with purulent nasal discharge and mildly erythematous pharynx

WHAT IS YOUR WORKUP?

What is your workup?

Lab tests
Blood, urine, stool, spinal tap

Radiological studies
X-ray or CT scan

Antibiotics
IV or IM or PO or none

Hospitalization versus discharge

What I fear Meningococcemia!!

Kupperman (1999)
Retrospective, 3 to 36 months evaluated for fever, discharged home, and subsequent BCx (+) for NM Associated with higher band count (14.3 vs. 7.3), no difference in temperature, WBC, ANC

Mandl (1997)
< 18 years with fever > 38 and petechiae 0/357 well appearing had serious invasive bacteremia or (+) CSF culture for NM All children with serious invasive NM disease were toxic

Algorithm for Fever and Petechiae

Complete sepsis w/u if ill appearing, immunocompromised, or generalized petechiae in an infant < 6 months Well appearing, generalized and > 6 months: obtain CBC, blood culture, GABHS if pharyngeal symptoms, to consider LP and PT/PTT
If WBC 5 to 15K, Absolute Band count < 500, ANC between 1.5 to 9K may discharge +/- IV antibiotics

No w/u if petechiae only above nipple line with history of significant cough or vomiting

Case 7
4 year old without PMH presents with fever for 4 days up to 104 and diffuse maculopapular rash PE: temp 105 (PO), HR 178, RR 38, sat 96% on RA, child is irritable and mildly consolable, has bilateral conjunctivitis, nasal congestion, and strawberry tongue

WHAT IS YOUR WORKUP?

What is your workup?

Lab tests
Blood, urine, stool, spinal tap

Radiological studies
X-ray or CT scan

Antibiotics
IV or IM or PO or none

Hospitalization versus discharge

Typical Kawasaki disease

Fever for 5 days and 4/5 of the following:
Bilateral conjunctival injection non purulent, limbus sparing Mucous membrane changes Erythema or edema of hands or feet Polymorphous rash Cervical lymphadenopathy > 1.5 cm

Treatment with IVIG within 10 days of disease onset decreases risk of coronary artery aneurysms from 15-20% to < 5%

Supporting laboratory findings

Leukocytosis with increased neutrophils Anemia Thrombocytosis after one week Elevated ESR and CRP Hypoalbuminemia Increased liver transaminases and GGT Sterile pyuria

Atypical Kawasaki
Witt (1999)
Retrospective review of children diagnosed with KD 36.2% KD did not meet AHA criteria 20% not meeting AHA criteria had coronary artery disease compared with 7% who met AHA criteria

So WWOD

Pearl: Role for IM antibiotics

Pearl: Role of alternating Acetaminophen and Ibuprofen

Weapon against FEVER PHOBIA

Fever is a good sign. It means that Xs body is able to fight his/her infection. I would be more worried if X did not have a fever. Kids who dont have proper antibodies arent able to produce a fever. If X feels warm and is not as active or playful, give him/her either Tylenol or Motrin. If Xs fever comes down and he is still not active or playful, then call your family physician.

So what should you do

Get excited about lethargy or dehydration or shortness of breath, but not fever Dont recheck temperatures prior to discharge Dont tell the family to return to the ED if fever persists Dont tell the family to alternate Tylenol and Motrin Tell families that fever may persist for 2 to 3 days even with antibiotics on board

Forget the fever and look at the kid

Look to the past ...

To find answers to the future...

Thank you

Any questions?