Pediatric Fever and Sepsis

ACEP=Clinical Policy of ACEP (Annals of EM 42:4, Oct 2003)

0-3 Months: Sepsis

0-1 Month: Amp (50-100 mg/kg) + Gent (2.5 mg/kg) or Amp + Cefotaxime (50 mg/kg)

1-3 Month: Amp + Cefotaxime or Amp +Ceftriaxone (50-100 mg/kg) or Amp + Chloramphenicol

3-24 Month: Ceftriaxone

>24 Month: Ceftriaxone

Immunocomprimised: Vanco (15 mg/kg) + Ceftazidime (50 mg/kg) + Ticarcillin (75 mg/kg)

WBC at any level has crappy sensitivity and specificity (Ann Emerg Med 2003; 42:2, 216-225)

and (Ann Emerg Med 42:2, 206, 2003)

Infants between 1-28 days with a fever should be presumed to have serious infection (ACEP)

The principal finding of this study is that UTIs were not uncommon in febrile, RSV-positive infants 0-90 days old in whom urine cultures were obtained (prevalence rate = 7.2%, 95% CI = 2.4-16.1) (Pediatric Emergency Care 2003; 19(5):314-319)

3-36 Months: Occult Bacteremia

bacteremia in children aged 224 months who presented to the pediatric ED in whom they found a prevalence of bacteremia of 1.9%. Of these pathogens, S. pneumoniae accounted for 83% and no H. flu was identified (JEM Aug 2003)

Latest data post HIB/strep pneumo vaccinations estimate 1.5-2%. 5-20% of those will progress to more serious infection. However when previously well children are looked at, 0.3% develop serious sequelae and only 0.03% will develop sepsis or meningitis. (ACEP)

It seems reasonable, therefore, to treat all patients who are in the high risk category with an initial dose of parenteral antibiotics, and if S. pneumoniae is found on blood culture, to consider outpatient treatment with appropriate oral antibiotics for 710 days in children over 23 months of age. Other pathogens grown on blood culture also merit considerationthere has been shown to be a rate of false-positive blood cultures (i.e., non-pathogenic) of around 0.9% [16]. For any patient aged 336 months whose blood culture reveals a pathogen, prompt re-evaluation is necessary. At least one study has shown that a single dose of parenteral antibiotics at the initial visit can eradicate bacteremia in patients with bacteremia caused by S. pneumoniae, H influenzae type b, Salmonella and N. meningitides [17]. If the patient is non-toxic, has no focal bacterial infection, and is well-appearing at a 24-h follow-up visit and received parenteral antibiotics at the first visit, a reasonable course of action would be to commence oral antibiotics, selected on the basis of what pathogen is grown and sensitivities (although duration of therapy is not well established). However, if patients with a positive blood culture have a persistent fever, are ill-appearing, have developed a bacterial focus of infection, or are less than 3 months of age, inpatient parenteral antibiotic therapy should be instituted [8].

one study found that of patients aged 224 months who were evaluated for occult bacteremia, those with otitis media were 2.2 times more likely to have bacteremia compared with those without a focus of infection [12].

Occult UTI

most prevalent in white females, UA routine?

UTI possibly as a result of posterior urethral valves.

Get UA and CX in males <1 y/o, and females<2 y/o (ACEP)

Nitrites are formed when bacteria break down urinary nitrates, especially gram neg enterics, it is specific but relatively insensitive. Leukocyte Esterase is a sign of WBCs in the urine, it is more sensitive, but less specific. The presence of either alone has a sensitivity of 88%, both together are 96% sensitive. Clear urine has a negative predictive value of 97% (ACEP)

Occult Pneumonia

7% of febrile children <2 y/o will have pneumonia. Occult pneumonia in 26% of fever without a source and a WBC>20,000. (ACEP) Good bet is to do the x-ray if there is the presence of one of the following: >50 breaths a minute, rales, rhonchi, retractions, wheezing, coryza, grunting, stridor, nasal flaring, or cough.

Presence of RSV doesn’t rule out SBI or bacteremia (Acad EM 2002; 9 5-7-518)

response to antipyretics does not change likelihood of infection (ACEP)

Meningitis

0-3 months Amp and Cefotaxime. If focal seizures, add acyclovir for possibility of HSV encephalitis. 50% will have skin lesions. If large RBCs in tap, with WBC<100, consider HSV very strongly.

>3 mo Ceftriaxone and Vanco. Consider Dexamethasone.

If aseptic meningitis in the summer, consider enteroviral meningitis from coxsackie or echovirus. Can have poly predominance if tapped early in the course of the disease.

Give Vanco in any sick kid, if not so sick, may defer if there are no gram positive diplococci in the CSF (Arch Dis Child 87, 207 September 2002)

Cat Scratch Disease

B. henselae

Sinusitis

Potts Puffy Tumor-soft, fluctuant forehead or scalp swelling from frontal sinusitis leading to osteomyelitis.

Acute Otitis Media (AOM)

if you are going to treat, use high dose amoxicillin (80-100 mg/kg) for 5 or 10 days.

Kawasaki Disease

mostly in Asians. Coronary artery aneurysms. Fever, nodes-cerv >1.5 unilat, mucocutaneous lesions or chapped lips, conjunctivitis s exudate, strawberry tongue, pharyngitis, palmar erythema or desquam, rash (maculopapular or raised placques)

Mucocutaneous lymph node syndrome

Highest incidence in Japan. Unknown etiology

Fever>5 days plus 4 of:

Bilat conjunctival injection s exudate
Injected or fissured lips, strawberry tongue, injected pharynx
Erythema of palms and soles (so bad, can not walk or hold things), edema of hands and feet
Rash (especially in perineal area)
Cervical Lymphadenopathy-unilateral >1.5cm

Also can see arthritis, myalgias, aseptic meningitis, hepatitis, diarrhea, sterile pyuria, uveitis, hydrops of gallbladder

Cardiac complications-myocarditis c CHF + effusions, dysrhythmias, coronary artery aneurysms

Early phase-1 to 2 weeks

Subacute-days 11-20 resolution of sx, greatest risk of coronary thrombosis

Convalescent-day 21-60-still at risk for death secondary to thrombosis

Ancillary exams-EKG, ECHO, CBC, C-reactive protein, ESR, LFTs, UA, blood cx, C-XR, strep antibody, throat cx

Gamma-globulin (2 g/kg over 12 hours) High dose ASA (20-25 mg/kg QID)

Preliminary data for Steroids (

J Pediatr 2003;142:61116)

The Septic Appearing Infant

any child <1 yr old with ill appearance and ashen color, pallor, or cyanosis.

Etiology can be viral, bacterial, or non-infectious

RSV, common in the winter, can present with cyanosis, respiratory distress, and apnea. HSV can cause encephalitis, DIC, septic shock, coma, and uncontrollable seizures. PCP should be considered in any Immunocomprimised infant. Consider congenital syphilis as well.

CAH can present with vomiting, lethargy, and irritability.

Replace glucose

(Class I)

Treat elevated potassium if ECG changes

Hydrocortisone 25 mg IVdraw extra blood before administration

(Class II)

Admit to NICU or PICU

Infant botulism.

Shaken baby syndrome

Hirschsprung’s enterocolitis

Early treatment of Sepsis shows mortaility benefit in pediatrics as well (Early Treatment of Pediatric Septic Shock in Community Hospitals Saves Lives Pediatrics 2003 Oct)

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