Fever Without Focus Management 3 to 36 months

Aka: Fever Without Focus Management 3 to 36 months, Fever Without Focus Management 2 to 24 months

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II. Indications

  1. Previously well child
  2. Febrile child 3 to 36 months (Guidelines are shifting toward 2 to 24 months)
  3. No obvious source of fever

III. History: Immunization Effects on Occult BacteremiaIncidence

  1. Haemophilus Influenzae Type B Vaccine (Hib Vaccine) introduced in U.S. 1985
    1. Occult BacteremiaIncidence with high fever dropped from 3-9% to 2-3%
    2. Primary cause of Occult Bacteremia changed to Streptococcus Pneumoniae
  2. Pneumococcal Conjugate Vaccine (Prenar 7) introduced in U.S. 2000
    1. Occult BacteremiaIncidence with high fever dropped from 2-3% to <0.5%
  3. Pneumococcal Conjugate Vaccine (Prenar 13) introduced in U.S. 2010
    1. Invasive pneumococcal disease dropped more than 50% (21.9 to 9.3 per 100,000)

IV. Approach: Triage

  1. Toxic appearing febrile child
    1. See Yale Observation Scale
    2. See Toxic Findings Suggestive of Occult Bacteremia
    3. Admit to hospital
    4. Full rule-out Sepsis workup
      1. See Fever Without Focus Labs
    5. Parenteral antibiotics
      1. See antibiotic selection in Step 5 below
  2. Non-toxic child with fever <39.0 C (<102.2 F)
    1. Up to 50% of children with serious Bacterial Infection appear well
    2. Avoid further diagnostic tests or antibiotics unless otherwise indicated
    3. Fever Symptomatic Treatment
    4. Careful examination to rule out serious infection
      1. Urinary Tract Infection (most common)
      2. Pneumonia (common)
      3. Abscess
      4. Cellulitis or Impetigo
      5. Acute Sinusitis
      6. Otitis Media
      7. Osteomyelitis
      8. Lymphadenitis
      9. Streptococcal Pharyngitis or Scarlet Fever
    5. Re-evaluation criteria
      1. Fever persists longer than 48 hours
      2. Condition deteriorates
    6. Consider Urinalysis and Urine Culture
      1. Girls age <12 months
      2. Boys age <6 months (or <12 months if uncircumcised)
      3. High fever (>39 C or 102 F)
      4. Persistent fever >24 hours
  3. Non-toxic child with fever >38.9 C (>102.1 F)
    1. See protocol below

V. Diagnosis: Predictors of Occult Bacteremia for ages 3-36 months

  1. See Toxic Findings Suggestive of Occult Bacteremia
  2. Precautions
    1. Unimmunized and underimmunized children bring back concerns from a pre-Hib era
  3. Pre-Hib Era: Fever in non-toxic child ages 3-36 months
    1. Temperature <39.5 C (103.1 F): 1.6% Positive Blood Culture
    2. Temperature <34.0 C (93.2 F): 2.1% Positive Blood Culture
    3. Temperature <41.0 C (105.8 F): 3.5% Positive Blood Culture
    4. Temperature >41.0 C (105.8 F): 9.3% Positive Blood Culture
  4. Post-Hib Era: Fever in non-toxic child ages 3-36 months
    1. Temperature <39.5 C (103.1 F): 0.9% Positive Blood Culture
    2. Temperature <34.0 C (93.2 F): 1.1% Positive Blood Culture
    3. Temperature <40.5 C (104.9 F): 1.7% Positive Blood Culture
    4. Temperature <41.0 C (105.8 F): 2.4% Positive Blood Culture
    5. Temperature >41.0 C (105.8 F): 2.8% Positive Blood Culture
  5. Post-Hib Era: WBC in non-toxic child ages 3-36 months
    1. WBC <5k C: 0.0% Positive Blood Culture
    2. WBC <10k C: 0.1% Positive Blood Culture
    3. WBC <15k C: 0.5% Positive Blood Culture
    4. WBC <20k C: 3.5% Positive Blood Culture
    5. WBC <25k C: 6.8% Positive Blood Culture
    6. WBC <30k C: 7.2% Positive Blood Culture
    7. WBC >30k C: 18.3% Positive Blood Culture

VI. Evaluation: Step 1 - Evaluate Fever by Rectal Temperature

  1. Fever with Rectal Temperature <102.2 F (39 C)
    1. Observe without testing (or consider Urinalysis)
    2. Follow-up if worsening or >48 hours of fever
  2. Fever with Rectal Temperature >102.2 F (39 C)
    1. Go to Step 2 unless criteria below met
    2. Consider Urinalysis (esp fever>2 days without source)
      1. Girls age <12 months
      2. Boys age <6 months (or <12 months if uncircumcised)
    3. Criteria for observation without labs, antibiotics
      1. See Toxic Findings Suggestive of Occult Bacteremia
      2. Non-toxic appearance
      3. Immunizations up-to-date
      4. Follow-up within 24-48 hours

VII. Evaluation: Step 2 - Obtain Initial Labs

  1. Labs
    1. Complete Blood Count with differential
    2. Urinalysis with Urine Culture
      1. Indicated in under 24 months or findings suggestive of UTI in 24-36 month old children
      2. False NegativeUrinalysis in 30% of children with positive Urine Culture
      3. Do not obtain bag urine (False Positive Rate 85%)
      4. May defer in a well appearing infant over age 3 months
        1. Must have close follow-up within 2-3 days
        2. Child is likely to have localizing symptoms by 2-3 days
        3. Informed Consent with parents
          1. Risk of initially missed Pyelonephritis vs urine catheterization
        4. Sacchetti and Newman in Majoewsky (2013) EM:Rap 13(5): 4-5
  2. Protocol
    1. Consider Chest XRay (see step 4) as indicated
    2. Go to step 3 unless criteria below are met
  3. Criteria for low-risk observation (24 hour follow-up)
    1. See Toxic Findings Suggestive of Occult Bacteremia
    2. White Blood Cell Count <15,000
    3. Absolute Neutrophil Count <10,000
    4. Urinalysis normal

VIII. Evaluation: Step 3 - Obtain Cultures

  1. See Fever Without Focus Labs
  2. Urine Culture
    1. Obtain in all cases in which Urinalysis is ordered
    2. Urinalysis alone is insufficient
  3. Blood Culture
    1. All cases in which labs abnormal above
    2. Obtain if antibiotics are given
  4. Cerebrospinal fluid (CSF) by Lumbar Puncture
    1. Indicated if neurologic or meningeal signs present in ill appearing children
    2. Not required if no meningeal and neurologic signs
      1. Should be a non-toxic appearing child over age 3 months
      2. Should have a normal White Blood Cell Count

IX. Evaluation: Step 4 - Additional Studies

  1. Chest XRay Indications
    1. Oxygen Saturation (O2 Sat) <95%
    2. Respiratory distress
    3. Tachypnea or Tachycardia out of proportion to fever
      1. Expect Heart Rate to increase 10 bpm for every increase in Temperature of 1 C
    4. Rales on lung auscultation
    5. Fever over 39.0 to 39.5 C (102.2 to 103.1 F) or higher
    6. Asymptomatic with White Blood Cell Count >20,000
  2. Stool Culture Indications
    1. Diarrhea
    2. Findings on stool exam that increase likelihood of Bacterial Infection
      1. Stool blood or mucus present
      2. Fecal Leukocytes > 5 WBCs per high powered field

X. Evaluation: Step 5 - Consider Antibiotics (fever >39 C)

  1. Decision to use antibiotics empirically
    1. Ill appearing young children with high fever should be treated and admitted
      1. See Toxic Findings Suggestive of Occult Bacteremia
      2. See approach to triage above
    2. Unimmunized or Underimmunized children and age <2 years (24 months)
      1. Consider antibiotics for White Blood Cell Count >15,000/uL
    3. Close interval follow-up without antibiotics is a reasonable approach
      1. Indicated in non-toxic appearing children
    4. Decision to start empiric antibiotics is one of clinical judgement
      1. Based on likelihood of serious underlying occult infection
  2. General empiric coverage
    1. Ceftriaxone (Rocephin) 50 mg/kg/day (max: 1 g)
  3. Suspected urinary tract source
    1. Cefotaxime (Claforan) 50 mg/kg IV every 8 hours or
    2. Cefixime (Suprax) 8 mg/kg twice daily for day one, then 8 mg/kg daily
  4. Suspected Pneumonia
    1. Amoxicillin 80 mg/kg/day divided every 8-12 hours or
    2. Azithromycin 10 mg/kg orally on day 1, then 5 mg/kg on days 2-5
      1. Alternative if Penicillin allergic
  5. If antibiotics are given, then:
    1. Obtain all cultures that are indicated in Step 3
    2. Re-evaluate within 24 hours

XI. Step 4: Disposition

  1. Admit patients with unreliable follow-up
  2. Follow-up
    1. Return within 24 hours if antibiotics started
    2. Return in 48 hours indication
      1. Fever persists
      2. Condition deteriorates
  3. Home management
    1. Observe for toxic appearance
    2. Fever Symptomatic Treatment

XII. Step 5: Blood Culture or Urine Culture positive

  1. Admit if child febrile or toxic appearance
  2. Outpatient antibiotics if afebrile and well-appearing

XIII. References

  1. Caskey and Ponce (2018) Crit Dec Emerg Med 32(11): 12-3
  2. Claudius, Seiden and Sacchetti in Swadron (2023) EM:Rap 23(1): 11-2
  3. Herman (2015) Crit Dec Emerg Med 29(12):14-19
  4. (1993) Ann Emerg Med 22(3):628-37 [PubMed]
  5. Baraff (2000) Ann Emerg Med 36:602-14 [PubMed]
  6. Baraff (1993) Pediatrics 92(1): 1-12 [PubMed]
  7. Daaleman (1996) Am Fam Physician 54(8):2503 [PubMed]
  8. Hamilton (2013) Am Fam Physician 87(4): 254-60 [PubMed]
  9. Kimmel (1996) Fam Pract Recert 18(7):69-85 [PubMed]
  10. Luszczak (2001) Am Fam Physician 64(7):1219-26 [PubMed]
  11. Lopez (1997) Postgrad Med 101(2):241-52 [PubMed]
  12. Sur (2007) Am Fam Physician 75:1805-11 [PubMed]

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