Pediatric fever of uncertain source

From Tintinalli

- Management of patients who are well-appearing, vaccinated, and no clinical source of fever

Age Group	Evaluation	Treatment
0-28d, ≥38C SBI incidence of ill appearing: 13%–21% if not ill appearing: <5%	CBC, blood Cx UA, Ucx CSF cell count, GS, Cx CXR (only if resp sx) Stool testing (if diarrhea present)	Admit Ampicillin 50mg/kg + (cefotaxime 50mg/kg or gentamicin 2.5mg/kg)
29-56d, ≥ 38.2 (100.8) (Philadelphia Protocol) SBI incidence of ill appearing: 13%–21% if not ill appearing: <5%	Same as for neonates	Discharge if: 1. WBC <15K but >5K and <20% bands 2. UA negative Admit and perform LP if above are not met Treat with CTX 50mg/kg (if CSF normal), 100mg/kg (if signs of meningitis)
57d-6mo, ≥38 Non-UTI SBI incidence is estimated to be negligible UTI is 3%–8%	UA and Ucx alone OR treat 57-90d using Philadelphia Protocol	Discharge if negative Treat UTI w/ cefixime 8mg/kg/d or cefpodoxime 10mg/kg/d divided into BID or cefdinir 14mg/kg/d x 7-10days as outpatient Admit and tx with CTX if fail criteria for d/c
57d-6mo, ≥39 (102.2) SBI incidence is estimated <1%; non-UTI SBI incidence is estimated to be negligible. UTI is 3%–8%	UA and Ucx alone OR UA and Ucx + CBC + blood cx	Discharge if negative Treat for UTI as above If WBC>15K consider treatment with CTX 50 mg/kg IV/IM, and follow-up in 24hr If WBC>20K consider CXR and CSF
6–36 mo Non-UTI SBI incidence is <0.4%  UTI in girls ≤8% UTI in boys (<12 mo) ≤ 2% Uncircumcised boys (1–2 y) remains 2%	UA and Ucx in: (girls 6-24mo) (circ 6-12mo) (uncirc 6-24mo)	Discharge if negative Treat for UTI as above as outpatient
>36mo	No further w/u is routinely necessary

Note: Preemies - Count age by estimated postconception date (not by actual delivery date) for 1st 90d

Harbor-UCLA Protocol

Background

• Medicine is an art as well as science, practice clinical judgment when using this guideline
• Preemies: Count age by estimated postconception date (not by actual delivery date) for 1st-90d
• If RSV+ or influenza+
  • Low risk of bacterial illness
  • Still some risk of concurrent UTI

0-28dy

Child Appearance	Work Up	Treatment	Disposition	Follow Up
T>=38 Toxic or Well	CBC Blood Cx UA, Ucx LP-CSF CXR^	Cefotaxime^^ 50-100 mg/kg Ampicillin 100-200 mg/kg Acyclovir^^^ 20 mg/kg	Admit	N/A

• ^CXR for (use clinical judgment):
  • Resp symptoms
  • Fever >48 hrs
  • Tachypnea
  • Decreased SaO2
• ^^Can use ceftriaxone 50-100 mg/kg, but concern for bilirubin displacement
• ^^^Acyclovir if:
  • HSV infection in baby or mother
  • CSF pleocytoisis
  • Concerning skin lesions
  • Seizures
  • Abnl LFTs

28dy-90dy

Appearance	Work Up	Treatment	Disposition	Follow Up
T>=38 + Toxic	CBC Blood Cx UA, Ucx LP-CSF CXR^	Cefotaxime^^ 50-100 mg/kg Ampicillin 100 mg/kg Acyclovir^^^ 20 mg/kg	Admit	NA
T>=38 + Well (Option 1)	CBC Blood Cx UA, UCx LP-CSF CXR^	Ceftriaxone (50mg/kg IM/IV)	If W/U (+) admit Outpatient^^^^	If W/U negative, meets outpt
T>=38 + Toxic (Option 2)	CBC Blood Cx UA, UCx CXR^	None For very well appearing 60-90 day olds (many would not use this option)	Outpatient^^^^

• ^CXR for (use clinical judgment):
  • Resp symptoms
  • Fever >48 hrs
  • Tachypnea
  • Decreased SaO2
• ^^Can use ceftriaxone 50-100 mg/kg, but concern for bilirubin displacement
• ^^^Acyclovir if:
  • HSV infection in baby or mother
  • CSF pleocytoisis
  • Concerning skin lesions
  • Seizures
  • Abnl LFTs
• ^^^^Outpatient

90dy-36mo

Appearance	Work Up	Treatment	Disposition	Follow Up
T>=39 + Toxic	CBC Blood Cx UA, UCx LP-CSF CXR^	Ceftriaxone (50-100mg/kg) OR Cefotaxime (50-100mg/kg) AND Consider Vanco (15mg/kg)^^^^	Admit	N/A
T>=39^^^^^ + Well + Prevnar^^	UA, UCx^^^ CXR^	If + W/U, oral abx	Outpatient
T>=39^^^^^ + Well + NO Prevnar^^	UA, UCx^^^ CBC CXR^	Ceftriaxone 50mg/kg if >15 WBC (also then consider BCx and LP)	Outpatient
T>=38-38.9 + Well	None Consider UA, CXR based on sx, etc	None	Outpatient	Return if worsening sx or fever persists >72hrs

• ^CXR for (use clinical judgment):
  • Resp symptoms
  • Fever >48 hrs
  • Tachypnea
  • Decreased SaO2
• ^^Prevnar = has 3 Prevnar or >=4 wks post 2nd Prevnar dose
• ^^^Urine workup for:
  • Circumcised males <6 months
  • Uncircumcised males <12 months
  • All females
• ^^^^Vancomycin if evidence of bacterial meningitis on CSF
• ^^^^^>=39.5 for 24-36mo

Work-Up Results

• WBC: 5-15, ANC <10k, <1,500 bands
• UA: (-)Gm Stain, (-) leuks, (-) nitrite, <5-10 wbc/hpf
• CSF: <8wbc, (-) Gm Stain
• When diarrhea present, <5 wbc

If low-risk criteria below not met, LP (if not done) and admit for inpt abx

Petechia

1. CBC
2. BCx
3. Ceftriaxone
4. LP depending on clinical

Facts and Figures from ACEP's Clinical Policy on Pediatric Fevers

7% of patients < 2 years old with fever have PNA, however the etiology (viral/bacterial) or even the presence of pneumonia has low inter-observer reliability even among pediatric radiologists

4% Prevalence of UTI with common other sources of fever (OM, viral URI, et cetera)

1.5-2% background prevalence of asymptomatic bacteruria in healthy afebrile controls

0.3% Rate of occult bactremia with healthy, well-appearing child who has a fever 2-24 months

0.3% of previously well children aged 3-36 months who have a fever without a source will develop significant sequelae, 0.03% will develop sepsis or meningitis

Concomitant RSV infection

In RSV+ (by PCR) neonates aged 0-28 days, 6.1% had UTIs and 3.7% were bactremic; there was no difference in rates of SBI between RSV+ and RSV- neonates in a large prospective multicenter study entailing 1,248 children

RSV+ infants aged 29-60 days, the SBI rate was 5.5%, all of which were UTIs

See Also

• UTI (Peds)
• Sepsis (Peds)
• Meningitis (Peds)
• Febrile Seizure

External Links

1.PEM ED Podcast and easy-to-follow diagnostic/treatment flow chart http://www.pemed.org/blog/2011/10/9/fever-of-unknown-source-part-1.html

Source

• Tintinalli
• Clinical Policy for Children Younger Than Three Years Presenting to the Emergency Department With Fever. Annuals of Emergency Medicine 2003 42. 530-545
• Risk of Serious Bacterial Infection in Young Febrile Infants With Respiratory Syncytial Virus Infections. Levine et all. PEDIATRICS Vol. 113 No. 6 June 1, 2004 pp. 1728 -1734