Pediatric fever of uncertain source
Background
- Medicine is an art as well as science, practice clinical judgment when using guidelines
- 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
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
Tintinalli Textbook Protocol
- 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)
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 ceftriaxone 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 ceftriaxone 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 ceftriaxone 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 |
Harbor-UCLA Protocol
0-28dy
Child Appearance | Work Up | Treatment | Disposition | Follow Up |
Temp ≥38°
Toxic or Well |
|
|
Admit | N/A |
^Acyclovir if:
28dy-90dy
Appearance | Work Up | Treatment | Disposition | Follow Up |
Temp≥38° + Toxic |
|
|
Admit | NA |
Temp≥°38 + Well |
|
|
Outpatient (if workup negative) |
Must have follow up within 24 hours if BCx positive at any time, admit for sepsis |
- 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
90dy-36mo
Appearance | Work Up | Treatment | Disposition | Follow Up |
T>=39 + Toxic |
|
Ceftriaxone (50-100mg/kg) OR Cefotaxime (50-100mg/kg) AND Consider vancomycin (15mg/kg)^^^^ |
Admit | N/A |
T>=39°C + Well + 3 Prevnar or ≥4 wks post 2nd Prevnar dose |
|
If + W/U, oral abx |
Outpatient | |
T>=39°C + Well + Non complete Prevnar |
|
Ceftriaxone 50mg/kg if >15 WBC (also then consider BCx and LP) |
Outpatient | |
T>=38-38.9°C + Well |
None Consider UA, CXR based on symptoms, etc |
None |
Outpatient | Return if worsening sx or fever persists >72hrs |
- Chest Xray should be ordered based on clinical judgment and:
- Resp symptoms
- Fever >48 hrs
- Tachypnea
- Decreased SaO2
- Refer to the Vaccination Schedule for information regarding Pneumococcal (Prevnar) vaccine
- Urine workup for:
- Circumcised males <6 months
- Uncircumcised males <12 months
- All females
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
Purpura or Petechia
- Skin changes are often the most concerning finding in a pediatric fever
Differential
Workup
- CBC
- Blood Cultures
- Basic Metabolic Panel (evaluating creatine)
- Chest Xray if pulmonary symptoms
- Lumbar Puncture depending on clinical findings and if not thrombocytopenic
Managment
- Treat source
Acetaminophen Pediatric Dosing Chart
Weight (kg) | Weight (lbs) | Age | Dosage (mg) |
3-4 | 6-11 | 0-3 mo | 40 |
5-7 | 12-17 | 4-11 mo | 80 |
8-10 | 18-23 | 1-2 y | 120 |
11-15 | 24-35 | 2-3 y | 160 |
16-21 | 36-47 | 4-5 y | 240 |
22-26 | 48-59 | 6-8 y | 320 |
27-32 | 60-71 | 9-10 y | 400 |
33-43 | 72-95 | 11 y | 480 |
- Dosage can be given q6 hours
See Also
External Links
Source s
- 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