WorkUp of Febrile Illness

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Work-Up of Febrile Illness

• Dr. Sarah Joiner
• Dr. Leslie Sawyer

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Rochester Criteria for Identifying Febrile
Infants at Low Risk for Serious Bacterial
Infection

• Infant appears generally well
• Infant has been previously healthy
• Born at term (gt/37 weeks of gestation)
• No perinatal antimicrobial therapy
• No treatment for unexplained hyperbilirubinemia
• No previous antimicrobial therapy
• No previous hospitalization
• No chronic or underlying illness
• Not hospitalized longer than mother
• Infant has no evidence of skin, soft tissue,
  bone, joint or ear infection
• Infant has these laboratory values
• White blood cell count of 5,000 to 15,000 per mm3
  (5 to 15 x 109 per L)
• Absolute band cell count of lt/1,500 per mm3
  (lt/1.5 x 109 per L)
• Ten or fewer white blood cells per high-power
  field on microscopic examination of urine
• Five or fewer white blood cells per high-power
  field on microscopic examination of stool in
  infant with diarrhea

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Full Septic Work-up

• CBC with differential
• Blood culture
• CRP
• Urinalysis
• Urine Culture
• CSF studies
• Gram stain and culture
• Glucose and protein
• Cell count and differential
• Tube 4 for HSV or save for future studies such as
  Enteroviral PCR
• CXR

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Partial Septic Work-up

• CBC with differential
• Blood culture if antibiotics started
• CRP
• Urinalysis
• Urine culture if antibiotics started
• Consider CXR
• Consider CSF if antibiotics started

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Neonates (0 to 60 days)Temp gt100.4

• Full septic workup
• CXR if pulmonary symptoms
• RRgt50, rales, rhonchi, retractions, wheezing,
  coryza, grunting, stridor, nasal flaring, cough
• Stool studies if diarrhea
• WBC, hemoccult, stool cx
• Admit to hospital on abx
• Ampicillin
• AND
• Gentamicin or Cefotaxime

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Neonates (0 to 60 days)Temp gt100.4

• If pt is ill-appearing, lethargic, has
  mucocutaneous vesicles, excessive irritability,
  seizures or CSF pleocytosis or RBC in CSF
  (non-traumatic), or maternal hx suspicious for
  HSV
• Presumptive tx with acyclovir after doing
• HSV PCR of CSF and
• CSF cx of eyes, nose, mouth, rectum

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Young Infants (61 to 90 days)

• Ill-appearing
• Full septic workup
• CXR if signs of pulmonary disease
• Stool studies if diarrhea
• Admit for abx
• Cefotaxime or Ceftriaxone

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Young Infants (61 to 90 days)

• Well-appearing
• Partial septic workup
• CXR if signs of pulmonary disease
• Stool studies if diarrhea
• Abnormal labs
• Admit and tx with empiric abx
• If normal labs, may manage as outpt
• Consider ceftriaxone 75mg/kg
• Follow-up in 24 hours
• Do CSF if abx or clinical S/S c/w meningitis

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3 to 36 months

• Workup and treatment based
• Patients PMH
• HPI
• Physical Exam
• Laboratory Evaluation (if done)

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3 to 36 months

• The older the patient, the more likely they can
  give you an indication of source of fever
• Younger patients more likely to require labwork
  to evaluate risk of serious bacterial infection
• Remember, most children will have a self-limited
  viral illness
• But some will have a serious infection that
  requires treatment
• Your clinical judgment will guide your evaluation
  and treatment

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Up To Date Criteria for Children 3 to 36 months

• Ill-appearing or unstable vital signs
• Full septic workup
• CXR if pulmonary symptoms
• Stool studies if diarrhea
• Admit to hospital and start ceftriaxone
• or clinda or macrolide if allergy

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Up To Date Criteria for Children 3 to 36 months

• Well-appearing fever greater than 101.5
• CBC, UA, Ucx
• Bld cx if WBC gt15K
• Abx (ceftriaxone, or clinda or macrolide) when
  WBC gt15K
• CXR when WBC gt20K
• Follow-up within 24 hours
• Abnormal UA Tx for UTI

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Up To Date Criteria for Children 3 to 36 months

• UA and UCx
• Girls 3-24 months
• Uncirc boys 3-12 months
• Circ boys 3-6 months
• NOT for
• Girls gt24 months (not potty-trained),
• Consider for girls gt24 months who are
  potty-trained
• Boys gt12 months uncirc,
• Boys gt6months circ

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Up To Date Criteria for Children 3 to 36 months

• When treated as an outpatient,
• Return for Medical Care when
• Fever gt48 hours
• Deterioration in clinical condition
• Positive cultures

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3 to 36 monthsOutpatient with positive cultures

• Urine cultures
• Return for evaluation
• Afebrile and well-appearing, can treat with oral
  abx
• Ill-appearing or with persistent, high fevers
• hospital admission for IV abx
• Blood cultures
• Hospitalized for IV abx if not contaminant
• Repeat cultures and follow clinically if felt to
  be contaminant

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Case 1

• 4wk female with T100.7 in clinic. No cough,
  congestion, rhinorrhea, fever, vomiting or
  diarrhea. Still taking po well. No change in
  activity.
• PMH born at 37 wks, no complications of
  pregnancy or delivery, went home with mom, no
  jaundice
• SH lives with mom and 2yo brother who is in
  daycare, pt stays at home with mom

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Case 1

• Physical Exam
• Gen alert, crying on exam, consolable by mom
• HEENT AFSF, no conjunctival erythema or
  discharge, OP moist (drooling)
• CV RRR no murmur, 2 B pulses
• Pulm CTAB no wheeze, retractions, flaring
  grunting or resp distress
• Abd soft, ND, BS
• Ext CR lt2sec, MAEW, no swelling or erythema
• Skin no rash or lesions

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Lab Workup

• Full septic workup
• Admit to hospital on ampicillin and cefotaxime
• Follow cultures

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Case 2

• 2 mo male with T 100.9.
• No cough, congestion, rhinorrhea, fever, vomiting
  or diarrhea. Still taking po well. No change in
  activity.
• PMH born at 41 wks, no complications of
  pregnancy or delivery, went home with mom, no
  jaundice
• SH lives with mom and dad, no siblings

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Case 2

• Physical Exam
• Gen alert, playful on exam
• HEENT AFSF, no conjunctival erythema or
  discharge, OP moist (drooling)
• CV RRR no murmur, 2 B pulses
• Pulm CTAB no wheeze, retractions, flaring
  grunting or resp distress
• Abd soft, ND, BS
• Ext CR lt2sec, MAEW, no swelling or erythema
• Skin no rash or lesions

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Case 2

• Labs partial septic workup
• CBC
• WBC 10K, no bandemia on differential
• CRP lt0.2
• UA wnl
• D/C home
• Consider ceftriaxone
• Consider CSF studies

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Case 3

• 2yo female with T 102 at home presents to clinic
  with cough, congestion, rhinorrhea. Pt not taking
  solid food well, but drinking well. Decreased
  activity with fever, but normal activity when
  fever under control with tylenol.
• PMH no significant, never had abx for any
  infection
• SH started daycare 1 month ago, mom smokes

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Case 3

• Physical Exam
• Gen active, alert
• HEENT R TM erythematous and bulging with
  purulent effusion, nasal discharge, OP moist
• Lungs clear no wheeze, crackles, resp distress
• Ext CR lt2sec
• Physical exam otherwise benign

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Case 3

• No labwork at this time
• Would d/c home on Amoxicillin
• Return to clinic if fevers persist past 48 more
  hours, symptoms worsen, or pt unable to take po