Rosen & Barkin's 5-Minute Emergency Medicine Consult (271 page)

• Oxygen saturation as mandatory 5th vital sign
  
• Resuscitate as appropriate.
  
• Determine duration of illness, degree, pattern and height of fever, use of antipyretics, past medical history, drug allergies, immunization status and history, recent medications/antibiotics, birth history if younger than 6 mo of age, exposures, feeding, activity, urine/bowel habits, travel history, and relevant review of systems.
  
• Search for underlying condition.
  
• Initiate antipyretic therapy.
  

• CBC with differential
  
• Urinalysis (UA) and culture in all male infants younger than 6 mo, uncircumcised male infants younger than 12 mo, and females younger than 2 yr. Urines for culture should be obtained by catheterization or suprapubic techniques.
  
• Blood culture:
  
  • The development of automated blood culture systems has led to more rapid detection of bacterial pathogens.
    
• CSF for cell counts, Gram stain, culture, protein, and glucose for toxic children and those 0–28/30 days of age; consider for nontoxic-appearing children 28–90 days of age as well as older ones in whom meningitis must be excluded.
  
• Stool for WBCs and culture when diarrhea present and suggestion of bacterial process
  
• C-reactive protein (CRP) elevation is commonly found and provides confirmatory data related to the presence of infection. The sedimentation rate (ESR) is also an adjunctive measure.
  
• Procalcitonin is being used in some settings as additional confirmatory information.
  

• CXR to exclude pneumonia if patient tachypneic or hypoxic
  
• Other studies as indicated to evaluate for specific underlying infection
  

See “Etiology.”

TREATMENT

• Resuscitate as appropriate.
  
• Begin cooling with antipyretics.
  

• Treat any life-threatening conditions.
  
• Antipyretic therapy
  
• Evaporative cooling techniques, such as sponge bath, have minimal role.
  

• Focal infections require evaluation and treatment.
  
• Toxic children require prompt septic workup and appropriate antibiotics.
  
• All potential life-threatening conditions must be excluded before treating a minor acute illness, which is more common.
  
• Infants 0–28 days old need a full sepsis workup: CBC, UA, cultures (blood, urine, CSF), lumbar puncture. A CXR should be obtained if there is suspicion for pneumonia:
  
  • Antibiotics: Ampicillin and either gentamicin or cefotaxime; consider acyclovir for infants at risk for HSV
    
  • Admit
    
• Well-appearing infants 29–90 days old need workup, selective antibiotic use (ceftriaxone), and re-evaluation within 24 hr:
  
  • H. influenzae
    type B and
    S. pneumoniae
    incidence has declined significantly with widespread vaccination.
    
  • It is currently reasonable to perform CBC, UA, blood culture, and urine culture with selective lumbar puncture, coupled with ceftriaxone IM in low-risk patients (see definition under Disposition) if re-evaluation in 24 hr is ensured. Well-appearing infants 60–90 days of age may be managed without LP or antibiotics selectively.
    
  • While lumbar puncture is optional in this setting, treatment with empiric antibiotics (ceftriaxone) without lumbar puncture may compromise subsequent re-evaluation.
    
  • Presence of RSV or influenza in this age group decreases but does not eliminate the risk of bacteremia and meningitis, but the rate of UTI is still appreciable.
    
• Children 3 mo–3 yr of age are evaluated selectively; those with recognizable viral syndrome (croup, stomatitis, varicella, bronchiolitis) generally do not require workup unless there is toxicity; antibiotic use is individualized for specific identifiable infections and pending appropriate cultures:
  
  • Well-appearing children with a temperature >39°C and no identifiable infection should prompt a UA and culture in all male infants younger than 6 mo, uncircumcised male infants younger than 12 mo, and females younger than 2 yr. Urine for culture should be obtained by catheterization or suprapubic techniques
    
  • Obtaining blood work or performing a lumbar puncture on a child 6 mo–3 yr of age is a clinical decision. Mandatory lumbar puncture in this age group based solely on the presence of fever has not been shown to be cost-effective and is not routinely recommended
    
  • Children 3–6 mo of age who are incompletely immunized and have WBC >15,000/mm
    ³
    and no identifiable infection may benefit from empiric antibiotics until preliminary blood cultures are available because of the risk of bacteremia.
    
  • Widespread immunization for
    Pneumococcus
    and
    H. influenzae
    have decreased the incidence of invasive infections by these bacteria.
    
• Immunocompromised children need aggressive evaluation, as do children with fever and petechiae/purpura or sickle cell disease.
  
• If methicillin-resistant
  S. aureus
  is considered, clindamycin or trimethoprim–sulfamethoxazole may be useful.
  
• Patients with underlying malignancy, central venous catheters, or ventricular peritoneal shunts may have few findings other than fever.
  

• Cefotaxime: 100–150 mg/kg/d IV divided q8h
  
• Ceftriaxone: 50–100 mg/kg/d IV/IM divided q12h
  
• Vancomycin: 40–60 mg/kg/d IV divided q6–8h if
  S. pneumoniae
  suspected until sensitivities defined
  
• Ampicillin: 150 mg/kg/d IV divided q4–6h
  
• Gentamicin: 5 mg/kg/d IV divided q8–12h
  

• Acetaminophen: 15 mg/kg per dose PO/PR (per rectum) q4–6h; do not exceed 5 doses/24 h
  
• Ibuprofen: 10 mg/kg per dose PO q6–8h
  
• Specific antibiotics for identified or specific conditions
  

FOLLOW-UP

• All toxic patients
  
• Infants 0–28 days of age with temperature >38°C
  
• Nontoxic infants 29–90 days of age with temperature >38°C who do not meet low-risk criteria (see definition under Discharge Criteria)
  
• Patients with fever and petechiae/purpura are generally admitted unless there is a specific nonlife-threatening cause.
  
• Immunocompromised children
  
• Poor compliance or follow-up
  

• Infants 29–90 days of age meeting low-risk criteria:
  
  • No prior hospitalizations, chronic illness, antibiotic therapy, prematurity
    
  • Reliable, mature parents with home phone, available transport, thermometer, and living in relative proximity to ED
    
  • No evidence of focal infection (except otitis media); nontoxic appearing; normal activity, perfusion, and hydration with age-appropriate vital signs
    
  • Normal WBC (5–15,000/mm
    ³
    ), urine (negative Gram stain of unspun urine or leukocyte esterase or <5 WBC/high power field [HPF]), stool (<5 WBC/HPF) if performed, and CSF (<8 WBC/mm
    ³
    and negative Gram stain) if performed
    
• Infants 3–36 mo of age who are nontoxic and previously healthy with good follow-up:
  
  • Antipyretics
    
• Follow-up by phone in 12–24 hr and re-evaluate in 24–48 hr with parental instructions to return if concerns develop or patient worsens.
  

Patients discharged with fever require close follow-up, usually by their primary care provider and guidelines of when to return with any change or worsening of signs or symptoms.

• Fever is the most common presenting complaint in children. It may reflect a life-threatening condition.
  
• Children under 28 days of age are generally treated empirically, pending culture results.
  
• Older children need close follow-up and specific discharge instructions.
  
• Subtle findings such as tachycardia, tachypnea, or altered mental status may be indicative of significant underlying infection.
  

• American Academy of Pediatrics.
  Red Book 2012: Report of the Committee on Infectious Diseases
  . 29th ed. Elk Grove, IL: AAP; 2012.
  
• Baraff LJ. Management of fever without source in infants and children.
  Ann Emerg Med
  . 2000;36:602–614.
  
• Gomez B, Bressan S, Mintegi S, et al. Diagnostic value of procalcitonin in well-appearing young febrile infants.
  Pediatrics.
  2012;130:815–822.
  
• Huppler AR, Eickhoff JC, Wald ER: Performance of low-risk criteria in the evaluation of young infants with fever: A review of the literature.
  Pediatrics.
  2010;125:228–233.
  
• Krief WI, Levine DA, Platt SL, et al. Influenza virus infection and the risk of serious bacterial infections in young febrile infants.
  Pediatrics
  . 2009;124:30–39.
  
• Ralston S, HillV, Waters A. Occultserious bacterial infection in infants younger than 60 to 90 days with bronchiolitis: A systemic review.
  ArchPediatr Adolesc Med.
  2011;165:951–956.
  
• Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management, Roberts KB. Urinary tract infection: Clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months.
  Pediatrics
  . 2011;128(3):595–610.
  

CODES

• 780.60 Fever, unspecified
  
• 780.61 Fever presenting with conditions classified elsewhere
  

BASICS