{"id":5343,"date":"2011-07-14T20:25:39","date_gmt":"2011-07-14T20:25:39","guid":{"rendered":"http:\/\/crashtext.org\/misc\/5343.htm\/"},"modified":"2011-10-02T19:51:51","modified_gmt":"2011-10-02T19:51:51","slug":"fever-sepsis","status":"publish","type":"post","link":"https:\/\/crashingpatient.com\/pediatrics\/fever-sepsis.htm\/","title":{"rendered":"Pediatric Fever and Sepsis"},"content":{"rendered":"<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p>ACEP=Clinical Policy of ACEP (Annals of EM 42:4, Oct 2003)<\/p>\n<h2><span class=\"ez-toc-section\" id=\"0-3_Months_Sepsis\"><\/span>0-3 Months:\u00a0 Sepsis<span class=\"ez-toc-section-end\"><\/span><\/h2>\n<p><a href=\"\/wp-content\/images\/part1\/1.gif\"> <img decoding=\"async\" src=\"\/wp-content\/images\/part1\/1_small.gif\" alt=\"\" \/><\/a><\/p>\n<p>0-1 Month:\u00a0 Amp (50-100 mg\/kg) + Gent (2.5 mg\/kg) or Amp + Cefotaxime (50 mg\/kg)<\/p>\n<p>1-3 Month:\u00a0 Amp + Cefotaxime or Amp +Ceftriaxone (50-100 mg\/kg) or Amp + Chloramphenicol<\/p>\n<p>3-24 Month:\u00a0 Ceftriaxone<\/p>\n<p>&gt;24 Month:\u00a0 Ceftriaxone<\/p>\n<p>Immunocomprimised:\u00a0 Vanco (15 mg\/kg) + Ceftazidime (50 mg\/kg) + Ticarcillin (75 mg\/kg)<\/p>\n<p>&nbsp;<\/p>\n<p>WBC at any level has crappy sensitivity and specificity (Ann Emerg Med 2003; 42:2, 216-225)<\/p>\n<p>and (Ann Emerg Med 42:2, 206, 2003)<\/p>\n<p>&nbsp;<\/p>\n<p>Infants between 1-28 days with a fever should be presumed to have serious infection (ACEP)<\/p>\n<p>&nbsp;<\/p>\n<p>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)<\/p>\n<p>&nbsp;<\/p>\n<h2><span class=\"ez-toc-section\" id=\"3-36_Months_Occult_Bacteremia\"><\/span>3-36 Months:\u00a0 Occult Bacteremia<span class=\"ez-toc-section-end\"><\/span><\/h2>\n<p><a href=\"\/wp-content\/images\/part1\/2.gif\"> <img decoding=\"async\" src=\"\/wp-content\/images\/part1\/2_small.gif\" alt=\"\" \/><\/a><\/p>\n<p>bacteremia in children aged 2\u009624 months who presented to the pediatric ED in whom they found a prevalence of bacteremia of 1.9%. Of these pathogens, <em>S. pneumoniae<\/em> accounted for 83% and no <em>H. flu<\/em> was identified (JEM Aug 2003)<\/p>\n<p>&nbsp;<\/p>\n<p>Latest data post HIB\/strep pneumo vaccinations estimate 1.5-2%.\u00a0 5-20% of those will progress to more serious infection.\u00a0 However when previously well children are looked at, 0.3% develop serious sequelae and only 0.03% will develop sepsis or meningitis. (ACEP)<\/p>\n<p>&nbsp;<\/p>\n<p>It seems reasonable, therefore, to treat all patients who are in the high risk category with an initial dose of parenteral antibiotics, and if <em>S. pneumoniae<\/em> is found on blood culture, to consider outpatient treatment with appropriate oral antibiotics for 7\u009610 days in children over 2\u00963 months of age. Other pathogens grown on blood culture also merit consideration\u0096\u0096there has been shown to be a rate of false-positive blood cultures (i.e., non-pathogenic) of around 0.9% [<a href=\"#bib16\">16<\/a>]. For any patient aged 3\u009636 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 <em>S. pneumoniae, H influenzae<\/em> type b, <em> Salmonella<\/em> and <em>N. meningitides<\/em> [<a href=\"#bib17\">17<\/a>]. 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 [<a href=\"#bib8\">8<\/a>].<\/p>\n<p>&nbsp;<\/p>\n<p>one study found that of patients aged 2\u009624 months who were evaluated for occult bacteremia, those with otitis media were 2.2 times <em>more<\/em> likely to have bacteremia compared with those without a focus of infection [<a href=\"#bib12\">12<\/a>].<\/p>\n<h4>Occult UTI<\/h4>\n<p>most prevalent in white females, UA routine?<\/p>\n<p>UTI possibly as a result of posterior urethral valves.<\/p>\n<p>Get UA and CX in males &lt;1 y\/o, and females&lt;2 y\/o (ACEP)<\/p>\n<p>Nitrites are formed when bacteria break down urinary nitrates, especially gram neg enterics, it is specific but relatively insensitive.\u00a0 Leukocyte Esterase is a sign of WBCs in the urine, it is more sensitive, but less specific.\u00a0 The presence of either alone has a sensitivity of 88%, both together are 96% sensitive.\u00a0 Clear urine has a negative predictive value of 97% (ACEP)<\/p>\n<h4>Occult Pneumonia<\/h4>\n<p>7% of febrile children &lt;2 y\/o will have pneumonia.\u00a0 Occult pneumonia in 26% of fever without a source and a WBC&gt;20,000. (ACEP)\u00a0 Good bet is to do the x-ray if there is the presence of one of the following:\u00a0 &gt;50 breaths a minute, rales, rhonchi, retractions, wheezing, coryza, grunting, stridor, nasal flaring, or cough.<\/p>\n<p>Presence of RSV doesn&#8217;t rule out SBI or bacteremia (Acad EM 2002; 9 5-7-518)<\/p>\n<p>response to antipyretics does not change likelihood of infection (ACEP)<\/p>\n<h2><span class=\"ez-toc-section\" id=\"Meningitis\"><\/span>Meningitis<span class=\"ez-toc-section-end\"><\/span><\/h2>\n<p>0-3 months Amp and Cefotaxime.\u00a0 If focal seizures, add acyclovir for possibility of HSV encephalitis.\u00a0 50% will have skin lesions.\u00a0 If large RBCs in tap, with WBC&lt;100, consider HSV very strongly.<\/p>\n<p>&gt;3 mo Ceftriaxone and Vanco.\u00a0 Consider Dexamethasone.<\/p>\n<p>If aseptic meningitis in the summer, consider enteroviral meningitis from coxsackie or echovirus.\u00a0 Can have poly predominance if tapped early in the course of the disease.<\/p>\n<p>&nbsp;<\/p>\n<p>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)<\/p>\n<h2><span class=\"ez-toc-section\" id=\"Cat_Scratch_Disease\"><\/span>Cat Scratch Disease<span class=\"ez-toc-section-end\"><\/span><\/h2>\n<p>B. henselae<\/p>\n<h2><span class=\"ez-toc-section\" id=\"Sinusitis\"><\/span>Sinusitis<span class=\"ez-toc-section-end\"><\/span><\/h2>\n<p>Pott\u0092s Puffy Tumor-soft, fluctuant forehead or scalp swelling from frontal sinusitis leading to osteomyelitis.<\/p>\n<h2><span class=\"ez-toc-section\" id=\"Acute_Otitis_Media_AOM\"><\/span>Acute Otitis Media (AOM)<span class=\"ez-toc-section-end\"><\/span><\/h2>\n<p>if you are going to treat, use high dose amoxicillin (80-100 mg\/kg) for 5 or 10 days.<\/p>\n<h2><span class=\"ez-toc-section\" id=\"Kawasaki_Disease\"><\/span><strong>Kawasaki Disease<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h2>\n<p>mostly in Asians.\u00a0 Coronary artery aneurysms.\u00a0 Fever, nodes-cerv &gt;1.5 unilat, mucocutaneous lesions or chapped lips, conjunctivitis s exudate, strawberry tongue, pharyngitis, palmar erythema or desquam, rash (maculopapular or raised placques)<\/p>\n<h3><\/h3>\n<p>Mucocutaneous lymph node syndrome<\/p>\n<p>Highest incidence in Japan.\u00a0 Unknown etiology<\/p>\n<p>&nbsp;<\/p>\n<p>Fever&gt;5 days plus 4 of:<\/p>\n<ul>\n<li>Bilat conjunctival injection s exudate<\/li>\n<li>Injected or fissured lips, strawberry tongue, injected pharynx<\/li>\n<li>Erythema of palms and soles (so bad, can not walk or hold things), edema of hands and feet<\/li>\n<li>Rash (especially in perineal area)<\/li>\n<li>Cervical Lymphadenopathy-unilateral &gt;1.5cm<\/li>\n<\/ul>\n<p>Also can see arthritis, myalgias, aseptic meningitis, hepatitis, diarrhea, sterile pyuria, uveitis, hydrops of gallbladder<\/p>\n<p>Cardiac complications-myocarditis c CHF + effusions, dysrhythmias, <strong>coronary artery aneurysms<\/strong><\/p>\n<p>Early phase-1 to 2 weeks<\/p>\n<p>Subacute-days 11-20 resolution of sx, greatest risk of coronary thrombosis<\/p>\n<p>Convalescent-day 21-60-still at risk for death secondary to thrombosis<\/p>\n<p>&nbsp;<\/p>\n<p>Ancillary exams-EKG, ECHO, CBC, C-reactive protein, ESR, LFTs, UA, blood cx, C-XR, strep antibody, throat cx<\/p>\n<p>Gamma-globulin (2 g\/kg over 12 hours)\u00a0 High dose ASA (20-25 mg\/kg QID)<\/p>\n<p>Preliminary data for Steroids (<\/p>\n<p><em>J Pediatr<\/em> 2003;<strong>142<\/strong>:611\u009616)<\/p>\n<h2><\/h2>\n<h2><\/h2>\n<h2><span class=\"ez-toc-section\" id=\"The_Septic_Appearing_Infant\"><\/span>The Septic Appearing Infant<span class=\"ez-toc-section-end\"><\/span><\/h2>\n<p>any child &lt;1 yr old with ill appearance and ashen color, pallor, or cyanosis.<\/p>\n<p>Etiology can be viral, bacterial, or non-infectious<\/p>\n<p>RSV, common in the winter, can present with cyanosis, respiratory distress, and apnea.\u00a0 HSV can cause encephalitis, DIC, septic shock, coma, and uncontrollable seizures.\u00a0 PCP should be considered in any Immunocomprimised infant.\u00a0 Consider congenital syphilis as well.<\/p>\n<p>&nbsp;<\/p>\n<p>CAH can present with vomiting, lethargy, and irritability.<\/p>\n<p>\u0095 Replace glucose<\/p>\n<p><strong>(Class I) <\/strong><\/p>\n<p>\u0095 Treat elevated potassium if ECG changes<\/p>\n<p>\u0095 Hydrocortisone 25 mg IV\u0097draw extra blood before administration<\/p>\n<p><strong>(Class II) <\/strong><\/p>\n<p>\u0095 Admit to NICU or PICU<\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p>Infant botulism.<\/p>\n<p>Shaken baby syndrome<\/p>\n<p>Hirschsprung&#8217;s enterocolitis<\/p>\n<p>&nbsp;<\/p>\n<p>Early treatment of Sepsis shows mortaility benefit in pediatrics as well (<strong>Early Treatment of Pediatric Septic Shock in Community Hospitals Saves Lives<\/strong> <strong>Pediatrics<\/strong> <em>2003 Oct)<\/em><\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p>|\u00a0\u00a0 \u00a0\u00a0 |\u00a0\u00a0 \u00a0\u00a0 |<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Array<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_genesis_hide_title":false,"_genesis_hide_breadcrumbs":false,"_genesis_hide_singular_image":false,"_genesis_hide_footer_widgets":false,"_genesis_custom_body_class":"","_genesis_custom_post_class":"","_genesis_layout":"","footnotes":""},"categories":[11],"tags":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v22.5 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Pediatric Fever and Sepsis - Crashing Patient<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/crashingpatient.com\/pediatrics\/fever-sepsis.htm\/\" \/>\n<meta name=\"twitter:label1\" content=\"Written by\" \/>\n\t<meta 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