Pediatric Case of the Week #1: Fever in a 1 month old

Case 1

Pt name: Jay Smith

Mode of arrival: brought by mother

Age/sex: 1 month old male

Initial Vital Signs: Temp 101.4 F (Rectal), BP 50/25, HR 200, RR 80, O2 Sat 95%

Initial Presentation: You walk into the room and see an infant held by his mother.  He appears limp and pale.  Mom reports that fever started 1 day ago and that child has been, “feeding very little.”

Initial questions?

Infant history: Breast/Bottle, Wet diapers, Cough, Diarrhea?

Prenatal history: Any hx of maternal infections: Group B, Herpes, HIV?  Prenatal Ultrasound: Cardiac or other congenital anomalies?

Birth history: Was infant premature or full term?, NICU stay? Was Mom given any antibiotics at delivery?

Initial actions?
 

IV access: IO?

20ml/kg bolus of NS and reassess

Labs (sepsis work up): cath UA, Blood Cultures

Imaging: CXR

Procedures: LP

Antiboitics: Empiric antibiotics?

Consider Antiviral: Acyclovir?

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This is both a challenging and a “not so” challenging case.  Hopefully you will not be seeing much of this at West Health, but the case illustrates a couple of very important points.

This kid is SICK!!!   You don’t need to memorize pediatric vital signs to know that this kid is sick/septic.  You know this.   And, you know that you’ll need to obtain IV/IO access and give fluids 20ml/kg bolus.

It is always valuable to take a prenatal history.  Ask about GBS, herpes, or generic “infectons”; ask about term/preterm, NICU stay.  Ask about current history of feeding, wet diapers.  And, sure, search for a focus. 

However once you know this is a sick kid <2 mos old with fever, in my opinion, the decision is relatively easy.  This child needs a full septic work up: cbc, blood culture, CXR, cath urine, and LP.  Followed by empiric antibiotics and admission.

In my opinion all infants < 2 mos of age with fever (100.4) are high risk need a full septic workup. 

The big debate for our group seems to come over whether or not (when working in a satellite emergency setting) a provider is obligated to perform the LP?  I would say yes, you should, but others would find it acceptable to start abx and transfer to a higher level of care. 

Remember that the antibiotic choice is, Ampicillin and Gent or Cefotaxime.  You shold avoid Rocephin in the age group <2 mos, because it can precipitate hyperbilirubiniemia. 

Final take home: Febrile infant <2 months needs a septic work up and septic treatment. 

Here is some additional information from medscape with a couple of additional references.  Please feel free to offer comments, debate these recommendations, or add resources. 

Evaluation of Neonates

A full sepsis evaluation is recommended in all febrile neonates. This includes a complete blood cell (CBC) count, blood culture, urinalysis, urine culture, and cerebrospinal fluid (CSF) analysis and culture. These patients should be hospitalized with intravenous antibiotics pending results of these cultures.

CSF studies

A lumbar puncture for CSF examination is recommended in all neonates younger than 28 days if empiric antibiotics are to be given or if the neonate had a seizure. CSF should be assessed for WBC count and differential, glucose level, protein level, Gram stain, and routine culture. CSF should be assayed for herpes simplex virus (HSV) using polymerase chain reaction (PCR) in all neonates in the first 28 days of life who appear ill, who have mucocutaneous lesions, or who have had a seizure.

Enterovirus PCR analysis should be performed on the CSF during the summer enteroviral season.

Urine and stool studies

Because the incidence of urinary tract infections (UTIs) is high in this age group, a urine specimen should be obtained for urinalysis and urine culture. A negative urine dipstick or urinalysis finding alone does not exclude the diagnosis of a UTI; only a negative urine culture finding can exclude this diagnosis.[7] A urine culture should be obtained via either a suprapubic aspiration or urethral catheterization, because bag urine specimens are frequently contaminated.

A stool culture is recommended when blood, mucus, or both are present in the stool; when diarrhea is present; and when more than 5 white blood cells (WBCs) per high-power field (HPF) are noted on methylene blue stain of fresh stool.

Pulmonary studies

A chest radiograph should be considered for neonates with signs of respiratory illness such as cough, coryza, tachypnea, rales, rhonchi, retractions, grunting, nasal flaring, or wheezing. During respiratory viral season, an attempt should be made to identify a respiratory viral etiology using direct fluorescent antigen (DFA) detection or PCR and viral culture on nasal wash specimens.

Treatment of Neonates and Young Infants

All febrile infants aged 28-60 days, after having a sepsis evaluation, should be hospitalized and empirically started on intravenous antibiotics pending culture results (see Workup). The antibiotic spectrum of coverage must include both community-acquired pathogens (eg, Streptococcus pneumoniae, Haemophilusinfluenzae, Moraxella catarrhalis, Neisseria meningitidis, late-onset group B Streptococcus [GBS], Staphylococcus aureus), perinatally acquired organisms (eg, early onset GBS, Escherichia coli, and other gram-negative organisms and Listeria monocytogenes), or hospital-acquired organisms in the neonate or infant who was recently hospitalized (eg, enteric gram-negative organisms, S aureus).

Empiric antibiotics

Ampicillin and gentamicin, or ampicillin and cefotaxime for the neonate, covers GBS, E coli, Listeria, and most S pneumoniae and N meningitides. For infants aged 1-2 months, recommended empiric coverage includes ampicillin, cefotaxime, and vancomycin to provide adequate coverage for community-acquired pathogens. All antibiotic dosages should be adequate to treat meningitis. For infants older than 2 months, vancomycin and cefotaxime are the empiric antibiotic choices. Vancomycin is especially important if the patient has evidence of soft-tissue infection, given the increasing prevalence of methicillin-resistant S aureus (MRSA), or a cerebrospinal fluid (CSF) profile consistent with bacterial meningitis to cover for antibiotic-resistant S pneumoniae.

Well-appearing and relatively well-appearing infants

Relatively well-appearing febrile infants younger than 28 days who are diagnosed with a viral respiratory illness should have a septic workup that includes cultures of blood, urine, and CSF. These infants should receive empiric antibacterial therapy in hospital until culture results are known.

Infants older than 28 days who look well and whose history, physical examination, and laboratory evaluation findings classify them as low risk can be treated as outpatients with ceftriaxone (50 mg/kg in a single intramuscular dose), as long as 24-hour follow-up can be ensured.

Infants older than 28 days who are diagnosed with bronchiolitis or influenza and are relatively well-appearing should undergo a limited laboratory evaluation, including complete blood cell (CBC) count with differential, blood culture, urinalysis, and urine culture. If the CBC count and urinalysis findings are benign, these patients can be initially managed without antibacterial therapy.

Ill-appearing neonates

Acyclovir (60 mg/kg/d divided every 8 h) is recommended for febrile neonates who appear ill, have mucocutaneous vesicles, experience seizures, or have a CSF pleocytosis.[10] In addition, viral cultures and direct fluorescent antigen detection should be performed on skin vesicles and conjunctival, nasopharyngeal, and rectal mucous membranes. CSF should be assessed for herpes simplex virus (HSV) and undergo polymerase chain reaction (PCR) and viral culture.

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http://hsc.unm.edu/emermed/resident_readings/EDArticles_PDF/Pediatrics/Annals%20EM_00%20-%20Manage%20of%20Fever%20without%20Source%20-%20Peds.pdf

http://pediatrics.uchicago.edu/chiefs/inpatient/documents/FebrileInfant.pdf