Kuliah Demam Blok 26 2014

Fever in Children

Blok 26 Agustus 2014

Case 1 v 4-month-old well-appearing girl admitted for croup and

respiratory distress. Develops fever to 39.1oC v What additional evaluation would you do at this point?

Case 2 v 10-year old boy with ALL, in induction, admitted for

febrile neutropenia. He had just received his first dose of ceftazidime when he developed another fever to 38.5oC, chills, and new dizziness shortly after receiving the antibiotics. v What would be the next steps in this patients

management?

Objectives v To know about fever: definition, classification,

etiology and patophysiology

v To assess patient with fever.

v To determine which patients are at high risk of developing serious bacterial infection.

v To initiate empiric therapy.

Definition of Fever

v Fever: an abnormal elevation of body temperature that occurs as part of a specific biologic response that is mediated and controlled by the central nervous system

v 0 to 28 to 30 days of age: rectal temperature 38.0C

v Healthy one- to three-month-old: rectal temperature 38.0

v Children 3 to 36 months: rectal temperatures 38.0

v Older children and adults: oral temperatures 37.8

Classification of Fever v Duration of fever: v Acute ( 14 days ), v Acute recurrent or periodic (episodic

fever separated by afebrile periods) v Chronic (> 14 days), which is more

commonly referred to as fever of unknown origin (FUO)

Fever

Fever with localizing

signs

Fever without

localizing signs

Fever of unknown

origin

Classification of Fever

Classification Definition Most frequent etiology

Duration of

fever

Fever with localizing signs

Acute febrile illness with focus infection which could be diagnosed by anamnesis & physical examination

Upper respiratory tract infection (URTI)

< 1 week

Fever without localizing signs

Acute febrile illness without focus infection diagnosed after anamnesis & physical examination

Viral infection, urinary tract infection (UTI)

< 1 week

Fever of unknown origin

Fever occured minimal 3 weeks, no established diagnosis yet after 1 week investigation at hospital

Infection, juvenile idiopathic arthritis

> 1 week

Classification of Fever

Organ system Diseases Upper airway infections Viral URTI, otitis media, tonsillitis, laryngitis,

herpetic stomatitis Pulmonary Bronkhiolitis, pneumonia Gastrointestinal Gastroenteritis, hepatitis, appendicitis CNS Meningitis, encephalitis Exanthems Campak, chicken pox Collagen Rheumathoid arthritis, Kawasaki disease Neoplasma Leukemia, lymphoma Tropics Kala azar, cickle cell anemia

Fever with Localized Signs Common Causes

Acute febrile illness with focus of infection, which can be diagnosed after history & physical examination

Fever without localizing signs

Serious infections occured in 1% cases: serious bacteriemic infections (SBIs)

Children 3-24 months have the highest incidence (3-4%),

aged 7-12 months demonstrating twice incidence association with high fever >39.50C

About 20% all febrile episodes demonstrate no localizing signs

Most common cause is a viral infection Most occuring during the first few years of life

Etiology Causes Diagnostic tools

Infections Bacteremia/sepsis Most virus (HH-6) UTI Malaria

Ill looking, high CRP, leukocytosis Well appearing, nomal CRP, WBC Urine dipsticks In malarial area

FUO Juvenile idiopathic arthritis

Pre-articular, rash, splenomegaly, high antinuclear factor, CRP

Post vaccination

DTwP, measles Time of fever onset in relation to the time of vaccination

Drug fever Most drug History of drug intake, diagnosis of exclusion

Fever without localized signs Common causes

What etiologies cause fever?

v Infectious

v Inflammatory

v Oncologic

v Other: CNS dysfunction, drug fever

v Life-threatening conditions

Infectious v Systemic

v Bacteremia, sepsis, meningitis, endocarditis

v Respiratory v URI, sinusitis, otitis media, pharyngitis, pneumonia,

bronchiolitis

v Abdominal v Urinary tract infection, abscess (liver, kidney, pelvis)

v Bone/joint infection

v Hardware infection v Central line, VP shunt, G-tube

Inflammatory v Kawasaki disease

v Juvenile inflammatory arthritis

v Lupus

v Inflammatory bowel disease

v Henoch-Schonlein purpura

Others v CNS dysfunction

v Drug fever

Pathophysiology of Fever

EVALUATION - History v History of present illness

v degree and duration of fever, method of measurement, and the dose and frequency of antipyretics (if any).

v Important associated symptoms that suggest serious illness include poor appetite, irritability, lethargy, and change in crying (eg, duration, character).

v Associated symptoms that may suggest the cause: vomiting, diarrhea (including presence of blood or mucus), cough, difficulty breathing, favoring of an extremity or joint, and strong or foul-smelling urine.

v Drug history should be reviewed for indications of drug-induced fever.

EVALUATION - History v Factors that predispose to infection are identified.

v In neonates: v prematurity, prolonged rupture of membranes, maternal

fever, and positive prenatal tests (usually for group B streptococcal infections, cytomegalovirus infections, or sexuallytransmitted diseases).

v For all children: v recent exposures to infection (including family and

caregiver infection), indwelling medical devices (eg, catheters, ventriculoperitoneal shunts), recent surgery, travel and environmental exposures (eg, to endemic areas, to ticks, mosquitoes, cats, farm animals, or reptiles), and known or suspected immune deficiencies.

EVALUATION - History v Review of systems:

v symptoms suggesting possible causes, including

v runny nose and congestion (viral URI),

v headache (sinusitis, Lyme disease, meningitis),

v ear pain or waking in the night with signs of discomfort (otitis media),

v cough or wheezing (pneumonia, bronchiolitis),

v abdominal pain (pneumonia, strep pharyngitis, gastroenteritis, UTI, abdominal abscess),

v back pain (pyelonephritis), and

v any history of joint swelling or redness (Lyme disease, osteomyelitis).

EVALUATION - History v A history of repeated infections (immunodeficiency) or

symptoms that suggest a chronic illness, such as poor weight gain or weight loss (TB, cancer), is identified.

v Certain symptoms can help direct the evaluation toward noninfectious causes; they include

v heart palpitations, sweating, and heat intolerance (hyperthyroidism) and

v recurrent or cyclic symptoms (a rheumatoid, inflammatory, or hereditary disorder).

EVALUATION - History v Past medical history should note

v previous fevers or infections and known conditions predisposing to infection (eg, congenital heart disease, sickle cell anemia, cancer, immunodeficiency).

v A family history of an autoimmune disorder or other hereditary conditions (eg, familial dysautonomia, familial Mediterranean fever) is sought.

v Vaccination history is reviewed to identify patients at risk of infections that can be prevented by a vaccine.

EVALUATION Physical Examination

v Vital signs: v abnormalities in temperature and respiratory rate.

v In ill-appearing children, BP should also be measured.

v Temperature should be measured rectally in infants for accuracy.

v Any child with cough, tachypnea, or labored breathing requires pulse oximetry.

EVALUATION Physical Examination

v Child's overall appearance and response to the examination are important. v A febrile child who is overly compliant or listless is of more

concern than one who is uncooperative.

v An irritable infant or child who is inconsolable is also of concern.

v The febrile child who looks quite ill, especially when the temperature has come down, is of great concern and requires in-depth evaluation and continued observation.

v Children who appear more comfortable after antipyretic therapy do not always have a benign disorder.

Age is important v >10 % of well-appearing young infants with a

temperature >38C has a serious bacterial infection or meningitis

v Only 39C (manifest bacteremia}

Serious Bacterial Infec1on (SBI) Syndromes Pneumonia Meningi,s Bacteremia Osteomyeli,s Urinary tract infec,on Bacterial Gastroenteri,s Sepsis

Allen C: Fever without a source in children 3 to 36 months of age.UpToDate CDROM 18.2,2010 Smitherman HF,Macias CG : Evaluation and management of fever in the neonate and young infant (< 3mo of age),UpToDate

CDROM 18.2,2010 Tolan RW :Fever Without a Focus , http://www.medscape.com, 2009

ETIOLOGY Serious Bacterial Infection (SBI)

Common Bacterial Etiology of SBI Streptococcus pneumoniae Streptococcus agalactiae Neisseria meningitidis Haemophilus influenzae type b Listeria monocytogenes Eschericia coli

Allen C: Fever without a source in children 3 to 36 months of age.UpToDate CDROM 18.2,2010 Smitherman HF,Macias CG : Evaluation and management of fever in the neonate and young infant (< 3mo of age),UpToDate

CDROM 18.2,2010 Tolan RW :Fever Without a Focus , http://www.medscape.com, 2009

Source: Jornal de Pediatrica - Vol. 85, No. 5, 2009

Yale Observa1on Scale (YOS) degree of Illness Indica,ons Assessment of febrile child ages 3-36 months

Predicts serious infec,on (Occult Bacteremia) Quan,fies "Toxic Appearance" in children

Observa1on Items 1 (Normal) 3 (Moderate Impairment)

5 (Severe Impairment)

Quality of cry Strong with normal tone or contentment without crying

Whimpering or sobbing Weak cry, moaning, or high-pitched cry

Reac1on to parent s1mula1on

Brief crying that stops or contentment without crying

IntermiJent crying Con1nual crying or limited response

Color Pink Acrocyano1c or pale extremi1es

Pale or cyano1c or moJled or ashen

State varia1on If awake, stays awake; if asleep, wakes up quickly upon s1mula1on

Eyes closed briefly while awake or awake with prolonged s1mula1on

Falls asleep or will not arouse

Hydra1on Skin normal, eyes normal, and mucous membranes moist

Skin and eyes normal and mouth slightly dry

Skin doughy or tented, dry mucous membranes, and/or sunken eyes

Response (eg, talk, smile) to social overtures

Smiling or alert (

Yale Observa1on Scale (YOS) degree of Illness Indica,ons Assessment of febrile child ages 3-36 months

Predicts serious infec,on (Occult Bacteremia) Quan,fies "Toxic Appearance" in children

A total score of less than 11 signifies a less than 3% probability of serious illness.

A total score 11-15 signifies a 26% probability serious illness

A total score of greater than 15 signifies 92 % probability of serious illness

Laboratory evaluation v What would you do if the patient has device (VP

shunt, tracheostomy, gastrostomy tube) or central line? v CBC with differential

v Blood culture

v CSF (tap VP shunt)

Laboratory evaluation v What would you do if the patient has a high risk for

sepsis? v Immunocompromised v Transplant recipient v Oncology patient

v CBC with differential v Blood culture v Urinalysis and urine culture

Laboratory evaluation v What would you do for an infant 2 months of age?

v CBC with differential

v Blood culture

v Urinalysis and urine culture

v Lumbar puncture

Laboratory evaluation v Who needs a urinalysis and urine culture?

v Circumcised males < 6 months

v Uncircumcised males < 1 year

v Females < 2 years

v Immunocompromised patients

v Patients with history of UTI/pyelonephritis

Laboratory evaluation v Who needs a lumbar puncture?

v Neonates 2 months v Ill-appearing v Altered mental status

v What tests do you send? v Gram stain and culture v Cell count and differential v Protein and glucose v Extra tube for additional studies

v Enteroviral PCR, HSV PCR, CA encephalitis project

Laboratory evaluation v Consider CRP, ESR

v Consider PT/PTT, fibrinogen

v Consider chest x-ray

v Consider nasopharyngeal DFA

v For immunosuppressed patients consider: v Viral PCR studies (ie CMV, EBV, HHV6)

v Additional imaging (ie ultrasound, CT scan)

Which patients are high-risk for serious bacterial infection?

v Neonates

v Transplant recipients v Bone marrow

v Solid organ

v Oncology patients v Undergoing therapy, mucositis, central line

v Most chemotherapy: nadir ~ 10 days after rx

v Asplenic patients, including sickle cell

Treatment for non-high risk patients

v May not need empiric antibiotics

v Consider the following issues: v Is patient clinically stable?

v Are the screening laboratory studies suggestive of infection?

Yale Observation Scale

A total score of less than 11 signifies a less than 3% probability of serious illness.

A total score 11-15 signifies a 26% probability serious illness

A total score of greater than 15 signifies 92 % probability of serious illness

Treatment for patients with central lines

v Ceftriaxone

v Vancomycin

Treatment for neonates 2 months

v If < 28 days old v Ampicillin AND cefotaxime OR v Ampicillin AND gentamicin

v Consider acyclovir

v If 29-60 days old v Ceftriaxone Ampicillin OR Vancomycin

v Until CSF results are known (cell count, protein, glucose), initiate therapy with meningitic dosing regimen

Treatment for febrile neutropenia v Broad-spectrum antibiotics with Pseudomonas

coverage v Ex: use ceftazidime or piperacillin-tazobactam

v Consider double coverage for possible resistant Pseudomonas v Ex: add amikacin or tobramycin

v Consider gram-positive coverage (central line, skin infections) v Ex: add vancomycin

v Consider anaerobic coverage (mucositis, typhlitis) v Ex: use piperacillin-tazobactam or add clindamycin

Take home points v Infections are the most common cause of

fever in children

v During assessment of a child with fever, pay close attention to vital sign changes, overall appearance, and potential sites of infection

v Closely monitor for clinical decompensation after antibiotic administration, particularly in patients at high-risk of developing sepsis

References v Baraff LJ. Management of fever without source in infants and

children. Ann Emerg Med. 2000. 36:602-14.

v Meckler G, Lindemulder S. Fever and neutropenia in pediatric patients with cancer. Emerg Med Clin N Am. 2009. 27:525-44.

v Palazzi EL. Approach to the child with fever of unknown origin. UpToDate. 2011

v Palazzi DL. Etiologies of fever of unknown origin. UpToDate. 2011.

v Tolan R. Fever of unknown origin: A diagnostic approach to this vexing problem. Clin Pediatr. 2010;49:207-13.

Kuliah Demam Blok 26 2014

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