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Sixty-five percent of all children between the ages of birth and two-years-of-age are brought to medical attention for some type of febrile episode. And 75% of these visits are for temperatures greater than or equal to 39 degrees. We have this fear that when the temperature gets up that high that we may be dealing with a significant bacterial infection. In 14% of these kids there’s no definable source for the fever and that’s the problem. So the child that you don’t have identifiable sources that you need to worry about, because that child could be either bacteremic. Could have meningitis or could have a bone or joint infection in fever infant, baby, newborn, babies.
First of all, I want to define fever. There is a lot of confusion about what really is a fever in a child. Remember that children are smaller, like little birds and little cats and little dogs, they tend to have higher metabolic rates and because of that their core temperatures are higher than that of an adult. So for a child, a rectal temperature of greater than or equal to 38C degrees, or 104F degrees - for those of you who still like to use Fahrenheit - is fever infant, baby, newborn, babies
A few caveats. Remember that fever documented at home by a reliable adult should be treated the same way you would treat a fever reported to you by a nurse or a colleague. This is primarily for the house officers that I mention this. But you all well know this and we need to respect these readings by well or reasonable adults at home. Always ask about recent immunizations. You’ve already had the lecture on immunizations and you know that some vaccines tend to give you
Serious bacterial infections can present with normal or subnormal temperatures. Keep that in mind. So an absence of a fever does not rule out a serious bacterial illness in a child. So don’t be lulled into a false sense of security. An issue that we are not seeing right now, this time of year, is over-bundling. One of the problems is what do you do with a child who shows up in your office or in your clinic or in the emergency room, just totally bundled up and about the only thing
Lastly, this issue. That the response to antipyretics does not predict the presence of bacteremia. I’m a dinosaur. I’ve practicing for a while and when I was a resident one of the things that our attendings liked to do, and the ER attendings liked to do, was give these kids a dose of Tylenol and see - aspirin, actually.
Why do we worry about this? Well, this is the prevalence of serious bacterial infections in infants less than or equal to 3 months of age who come in with fevers of 39C degrees or greater. We are defining serious bacterial infections as these: meningitis, sepsis, bone and joint infections, urinary tract infections, pneumonia and
The players for kids less than 60 days of age are clearly different than the players of kids greater than 60 days of age. In this group, in the less than 60 days of age group, we are talking about group B beta streptococcus, E. coli, Listeria monocytogenes occasionally, staphylococcus, streptococcus, staphylococcus species and primarily staphylococcus aureus. Streptococcus pneumoniae and Hemophilus influenzae are starting to be seen more frequently. We’ve actually seen a few cases of kids who’ve had strep pneumoniae sepsis as a neonate. So neonatal sepsis due to strep pneumoniae. Probably has to do with inadequate antibodies transferred from the mother to the baby. The same thing with Hemophilus influenzae. We are not seeing Hemophilus influenzae type B disease anymore in kids
In the older age group - that is, the 3 to 36 month of age group - the incidence of occult bacteremia, which is a frequent cause of fever of undetermined origin, seems to have decreased over time. McCarthy, which is one of the first studies out there in 1977, had an occult rate of bacteremia of about 7.1%. We are now somewhere around 3% to 5%. Most people are quoting numbers of 3% to 5%. So about 3 to 5 out of every 100 kids that show up with a temperature greater than 39C or greater or equal to 39C degrees is going to have occult bacteremia. The players in this have clearly, clearly changed. From the 70’s to the early 80’s
So summarizing the data for kids 3 to 36 months of age, the prevalence is about 3% to 5%. It really doesn’t matter where you are practicing medicine. You are going to see the same prevalence. The organism again is streptococcus pneumoniae. That’s the major player we are seeing these days.
Why do we worry about occult bacteremia? What’s the big deal here? So you’ve got a few bacteria floating around in your blood stream, who cares? Again, this is a dead disease but it drives home the point as to why this bacteria was targeted for vaccine development very early on. If you look at Hemophilus influenzae B and you ask the question - here’s a kid who shows up in the emergency room, I draw a blood culture and I do nothing else but send him out the door. There are
Neisseria meningitidis is a little different. In a lot of patients out there - maybe 12 in one study - eight of these actually received antibiotics believe it or not and they still had this outcome. So persistence of bacteremia in one-quarter of those patients, meningitis in another quarter and in 17% they were dead on arrival because of, as you know, the progression of this disease. So this is not a good one to have floating around for a long period of time. The _ which is Salmonella
Can you tell these kids apart by looking at a clinical scoring scale? Again, it depends on what clinical scoring scale you are using but in general the vast majority of them fail to identify correctly the vast majority of kids who are bacteremic or non-bacteremic. Here’s just one of multiple studies, and I’ll quickly summarize it. This is 688 children between the ages of 3 and 24 months. Temperature was greater than or equal to 39.5C, so these kids were highly febrile. They had a high
Toxic infants. If you look at these kids and you ask the straight question, does the kid look toxic? In other words, is this a kid that really looks sick in front of you? By toxic, we are looking at a kid who is lethargic, has poor perfusion, hyperventilation, hypoventilation or cyanosis. If the answer is yes, then there is no question that that kid is going to be a high risk for serious bacterial infection. The numbers speak for themselves; 17% are going to have some type of a serious
To do that we use this scale. These are low risk clinical criteria, and using this coupled with some laboratory data you can cull those kids that are lowest risk for serious bacterial infections when they show up with fever. So here’s what you need to do. A series of questions have to be asked. The first one is: is this a previously healthy child? Was the child in the neonatal intensive care unit? If it was, then it is no longer in the low risk category. Was the child ill in the last three or four weeks? Does the child have otitis media or something, or does it have pneumonia? If the answer is yes then the child is no longer in the low risk group and
The laboratory data are as follows: when examining the patient’s blood count, the white blood cell count - the total count - should be between 5,000 and 15, 000. There are really some very good studies to show that once you deviate from those parameters you start to see kids that get into trouble.
What are the appropriate antibiotics for a child less than 30 days of age? You can have your choice. Some people like the traditional ampicillin plus gentamicin. The ampicillin/gentamicin should cover most of the pathogens we’ve talked about. Newer regimens include things using like cefotaxime and ampicillin. The common denominator in both of these is the ampicillin component and that’s because that component offers coverage for Listeria monocytogenes. Listeria is not covered by the cephalosporins alone. So you need that one coverage. We don’t use ceftriaxone in this group, as you all know, because it displaces bilirubin from its albumin-binding sites, and so it can lead to kernicterus or jaundice. That’s why we don’t use ceftriaxone on a kid less than a month of age. Otherwise we probably would. It’s a good drug.
What about the kid that’s 28 to 90 days of age? This is where your algorithm for the low risk high risk comes into play. Here again you begin with the non-toxic low risk child. And the first question is, is he in that group? Yes or no? If he’s not, if he falls out of the low risk group, then he should be admitted. You should do the complete work-up, including the lumbar puncture and parenteral antibiotics and I’ll talk about this in a minute. On the other hand, if he does meet this low risk group then you have the option of an outpatient management. That should include - there are two options here, I’m going to talk about option one first. In option