UTIbacteremiameningitisosteobacterial gastropneumoniacellulitisseptic arthritis

femalewhitefever >39uncircumcized boysno other source found

161. Ped Fever Flashcards by Tegan Turner

Fever defn in ped

>/= 38

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Most reliable temp for fever?

rectal thermom

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Who should a rectal thermometer not be used in?

immunocomp

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MC fever infectious examples in kids

<div>
<div>
<div>
<div>
<div>upper respiratory infections, viral gastro-
enteritis, croup, bronchiolitis, stomatitis, roseola, infectious mononu-
cleosis, and varicella </div>
</div>
</div>
</div></div>

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Serious bacterial infection defn

presence of pathogenic bacteria in a previously sterile site

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Examples of SBI

UTI<br></br>bacteremia<br></br>meningitis<br></br>osteo<br></br>bacterial gastro<br></br>pneumonia<br></br>cellulitis<br></br>septic arthritis

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Hyperpyrexia is a temp over 40 - it is assoc with?

SBI

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Most common bacterial concerning organisms in neonates

GBS<br></br>Listeria<br></br>HSV

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Most common bacterial concerning organisms in infants 1-2mo of age

strep pneumo<br></br>neisseria<br></br>ecoli/enterococcus

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In all children yo than 3mo with SBI, mc etiology is __, followed by __ and __

UTI<br></br>bacteremia, meningitis

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Occult bacteremia defn

presence of pathogenic bacteria in bloodstream of a well appearing febrile child, absence of focus of infection<br></br>-typically kids >39 degrees aged 3-36mo but look well

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RF for UTI in kids

female<br></br>white<br></br>fever >39<br></br>uncircumcized boys<br></br>no other source found

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Common bacterial illness in school age children and adol

focal infection: strep pharyngitis, cellulitis, pneumonia, bacteremia, meningits

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Peak of N meningitidis

<12mo and adolescence (college)

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<div>
<div>
<div>
<div>
<div>Maternal anti-
bodies confer some protection after birth, but the infant’s immune sys-
tem is initially inadequate, particularly T-cell function and the ability
to mount an immunoglobulin G response to infection. Which bugs are particularly high risk SBI for newborn? </div>
</div>
</div>
</div></div>

GBS<br></br>chlam<br></br>N gonorrhea

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Why are yo kids at risk for disseminated disease?

unable to mount immune response until about 2-3mo of life

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Infants yo <28 days - what parts of hx esp important?

GA<br></br>birth hx<br></br>HSV/GBS

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<div>
<div>
<div>
<div>
<div>The neonate who... should have a full SBI evaluation, irrespective of temperature. </div>
</div>
</div>
</div></div>

refuses to feed

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What WBC component may be a sign of SBI or early sepsis?

Leukopenia <5000

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WBC up/N/low:<br></br>a. Pneumococcal<br></br>b. N meningitidis<br></br>c. H influ

high<br></br>N<br></br>N

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Severe leukocytosis (ie >25000) - get what test/what disease?

cxr - pneumonia

ANC >10 000 suggests increase risk of ? bacteremia in a febrile child

pneumococcal

Recommend tx with ? for incompletely immunz child with WBC of more than 15000

ceftr

Procalcitonin greater than __ ng/mL is highly spe- cific for SBI, though some clinicians use a lower cutoff (>0.2 ng/mL) to increase sensitivity

0.5

Both __ and procalcitonin appear to be more sensitive and specific than the WBC alone

CRP

Child: bacteremia is often accurately detected even if only __-__ mL of blood is obtained

0.5 to 1

Pathogens isolated in the first __ hours are more likely to be true pathogens than are bacteria isolated after __ hours

24
24

It is currently recommended that febrile infants with documented UTIs undergo ___ to evaluate for urinary tract anomalie

renal ultrasonography

or infants with signs of uro- sepsis or not improving within 24 hours of antibiotic administration, a ? should be performed performed to evaluate for __ __ or rare complications, such as renal or perirenal abscesses.

an ultrasound should be
obstructive uropa- thy

___ is not indicated after the first febrile UTI in children unless renal ultrasonography reveals evidence of high-grade vesicoureteral reflux or scarring.

Void- ing cystourethrography

Reliable methods for urine in non toilet trained kids

1. bladder cath
2. suprapubic aspiration - false positive, then need to confirmatory test/risks abx

Because dipstick and microscopic analysis have lower sensitivities, most experts recom- mend sending urine for culture in high-risk groups - who are these?

(febrile girls <24 months old, uncircumcised boys <12 months old, and circumcised boys <6 months old).

A positive urine culture is defined as the growth of more than __ of a single uropathogen in urine obtained via cathe- terization or suprapubic aspirate.

50,000 CFU/mL

A sample of cerebrospinal fluid (CSF) should be obtained from any child with signs and symptoms of ____

meningitis

What should CSF be sent for?

1. gram stain and culture
2. pro
3. glucose
4. other including HSV PCR

CSF culture of a pathogenic bacterium is considered the __ __ for dx

gold stnd

Children without any of the following criteria have a low risk (0.1%) of bacterial meningitis: 5

1. + CSF gram stain
2. CSF ANC of 1000 cells/ml or more
3. PRO at least 80mg/dL
4. peripheral blood ANC 10 000 of more
5. hx of seizure prior to presentation

CI to LP

1. cellulits over site
2. Cardiopulmonary unstable
3. bleeding diathesis
4. plt count <50 000
5. focal neuro deficits
6. incr ICP

The presence of more than five WBCs per high-power field in the stool of a febrile child should trigger a culture of stool for what 5 bugs?

Enterotoxic ecoli
Yersinia
campy
shigella
salmonella

Pt with sickle cell disease are at particular risk for focal complications, such as OM, from ___ (bacteria?)

salmonella

hildren younger than 6 months old may present with tachypnea as the sole finding of __ __

bacterial pneumonia.

Occult pneumonia can also occur in a small per- centage of children, particularly in the highly febrile child (>102.2°F [39.0°C]) without an apparent source of fever and an elevated __

ANC

**Given the exceedingly low rates of bactere- mia and meningitis, it is reasonable to consider a selective, de-escalated evaluation (i.e., urine and urine culture only) of well-appearing infants who have positive viral testing in the ED. Ill-appearing infants or neo- nates (28 days old and younger) should still undergo a full evaluation for SBI.

Management: approach (basic) to febrile infant and child

ABC
IV O2 monitors
20ml/kg isotonic, repeat to 60ml/kg over 60 mins if hypovolemia cont
if still low: NE 0.05 to 2 microgram per kg per min titrated to BP
Cultures if possible pre abx

Steriliza- tion of the CSF starts to occur once antibiotic administration has been initiated—within ___in patients with meningococ- cal meningitis and within ___ in patients with pneumococcal meningitis.

15 mins to 2 hours
4 to 10 hours

Highest risk period of HSV disease in a neonate?

2-12 days old

Noninfectious causes of a septic appearing neonate:

-inborn error metabolism
-CAH salt wasting crisis
-undiagnosed congenital heart disease

Infants 0 to 28 days - how do I manage them?

(CBC) with differential,

blood culture,

urinalysis and urine culture, and

lumbar puncture.

All neonates should be admitted to the hospital with empirical antibiotics while awaiting culture results.

Abx dosing for 0-28 days fever:

amp 50-100mg/kg q6-12h
+
gent 4-5mg/kg q24-48h
or cefepime 50mg/kg q8-12h
+/- acyclovir for HSV

Dose acyclovir if worried about HSV in 0-28d old?

20mg/kg q8h if adequate Cr

Infants 29-90 days old: bacterial pathogens to cover

Listeria
GBS
H influ
S pneumoniae
N meningitis

Infants 29-90 days old: abx preference, including if R to S pneumo? (3)

ceftriaxone 50mg/kg IV q12h, amp 50-100mg/kg q6-12h
vanco 10-20mg/kg q6-8h

Major differences Phili, Rochester, Boston criteria for febrile infant management <3mo

1. Phili: 29-60 days, Rochester <60, Boston 28-89 days
temp for Phili >38.2, R and B 38 only
2. P WBC <15, Roch WBC 5-15, B <20
Low risk go home with abx in BOston only (otherwise home and no abx)
3. CSF included P and B
4. stool in roch
5. CXR P and B
6. Boston has no sn and sp

Major similarities Phili, Rochester, Boston criteria for febrile infant management <3mo

1. well with no focus on PE
2. all include UA <10 wbc per hpf
3. adm and IV abx if high risk

Infants 3-36mo: MC fever cause?

viral illness: viral upper respiratory infections, croup, bronchiolitis, stomatitis (typically caused by HSV or coxsackievirus), gastroenteritis, roseola, and fifth disease (parvovirus B19 infection).

Infants 3-36mo: what focal infections become more common in this group?

1. pyelo
2. periorbital cellulits
3. bacterial pharygnitis/GAS
4. SEptic arthr
5. RPA
6. Meningitis
7. Bact pneumonia

furthermore, classic meningeal signs, such as nuchal rigidity, are seen in less than __% of infants (0 to 6 months old) with bacterial meningitis.

Child 3-36mo: High fever, no source of infection (>39): tests and tx if wbc high

A typical evaluation included a CBC and blood culture, and empirical antibiotic therapy was prescribed for children with WBC counts above 15,000/mm3.

**Although the incidence of pneumococcal bacteremia has declined in infants 3 to 36 months old because of the deliberate campaign to vac- cinate, infants 3 to 6 months old have not yet completed the primary series of immunizations against S. pneumoniae and to a lesser extent against H. influenzae. Despite being “incompletely vaccinated” at this age, the rate of bacteremia is exceedingly low, and we do not recom- mend routine screening in this age group.

Additional signs and symptoms that may suggest meningococcemia are (4)

1. purpuric rash
2. bandemia
3. limb pain
4. exposure to person with disease

Incidence of occult bacteremia decreases after _ years old

What diseases (bact 2) and viral become more common after 3yoa?

1. PTA, cellulitis
2. mono

In children >3, start to consider ? pneumonia as cause

mycoplasma

If a pt >3yo has an abscess, in add to I+D, tx with abx for who?

we recommend antibiotic therapy in addition to incision and drainage, especially for patients with large abscesses (>5 cm), cellulitis, or fever.

What are possible oral abx for MRSA concerning abscesses?

TMP/SMX
clindamycin
doxy if >8yoa

Meningococcal classic presentation of disease?

rapidly progressive, presenting with fever, headache, and a stiff neck

Some of first signs of meningococcal infection include:

include leg pain, cold hands and feet, and abnormal skin mottling.

How to tx meningococcemia in pt >3yo?

full septic eval
adm - abx - ceftr 100mg/kg IV
empiric tx with abx until results blood and CSF

Who should have the quadvalent meningococcal conjugate vaccine?

1. adol in college/close quarters
2. yo child with func/anatomic asplenia
3. compleemnt component deficiencies
4. children travel and reside in other countries where disease hyperendemic

Febrile seizure: defn

1.6mo-6y
2. fever
3. GTC
4. 1 in 24 hours
5. No neuro abnormality
6. <15 mins

What is thought to be an at risk period for febrile seizure?

rapid rise of devere or deferesence rather than abs height

Risk of epilepsy N child vs febrile seizure

The risk of epilepsy in the general popula- tion is thought to be 0.5% to 1%, whereas the risk in a patient who has had a febrile seizure is 1% to 2%

Febrile seizure: complex defn

1. prolonged >15 mins
2. focal
3. multiple in 24h
4. outside <6mo or >6y

**The AAP suggests that a lumbar puncture be performed in any child with signs of meningeal irritation after the first febrile seizure and be considered in symptomatic children who are incom- pletely immunized or have received prior antibiotic therapy.

Febrile status epilepticus, in contrast to a simple or even complex febrile seizure, carries a higher risk of ? - what test to do?

meningitis
LP

Fever and petechiae ddx

1. meningitis
2. Rocky mountain spotted fever
3. DIC
4. pneumoccoal bacteremia
5. GAS infection
6. Viral infection
7. ITP
8. HSP
9. Leukemia

Petechia due to vomiting or coughing are typically confined to ?

above nipple line

Fever and petechiae work up:

CBC
CRP
blood culture
+if pharyngitis concern - rapid strep test

What triad of "or" results is consistent with invasive bacteremia?

1. fever >38 and petechiae
2. WBC <5000 or >15000
3. Abnormal coagulation studies

Kawasaki disease: considered in any child or infant with fever >_ days

Kawasaki disease: Why is dx important?

main complication is development of coronary artery aneurysm

Kawasaki disease: lab anormalities?

leukocytosis
thrombocytosis (plt as high as 1 mill)
CRP/ESR high

Kawasaki disease: if suspected, how to tx?

adm
IVIG 2g/kg q10-12hours
aspirin - dose 80-100mg/kg divided into q6h
peds cardio consult for echo

TSS: what is this?

toxin mediated clinical syndrome caused by S aureus or similar disease by GAS

TSS: what is implicated toxin?

TSS toxin 1

TSS: clinical manifestation

fever >38.9
hypotension
diffuse erythroderma - "full body sunburn"
multisystem involvement - GI, pharynx, myalgias, AMS

TSS: lab findings

elevatedCK
elevated BUN/Cr
transaminitis
thrombocytopenia

TSS: tx

fluid resus at 20mg/kg
antistaph abx - clindamycin to stop toxin at 20-40mg/kg/day in TID dosing
vancomycin 10-20m/kg IV q6-8h

Neutropenia definition

ANC <500 or <1000 that is continually decreasing

What bugs do we worry about in kids neutropenia?

staph strep pseudomonas
sp to ca pt: stomatitis, typhilitis

What is typhilitis?

NEC of terminal ileum and cecum, can see in oncology pt with febrile neutropenia (kids)

Febrile neutropenia kids: goal of arrival to abx therapy in fewer than ? mins

Febrile neutropenia kids: labs

CBC, differential
blood cultures, urine?

Febrile neutropenia kids: when to start empiric therapy? what therapy?

as soon as labs are drawn, don't wait for results
cefepime 50mg/kg IV q8-12h or ceftazadime 50mg/kg IVq8h
add vanco if concerned for line infection or SSTI: 10-20mg/kg IV q6-8h

If in consultation with oncologist, decide to tx febrile neutropenia kiddo as outpt, can tx with what? what kind of follow up?

ceftriaxone 50mg/kg q24h
f/u every 24 hours

Kids with AIDS: concern for which specific/unique infections? (6+ usual infection)

cryptococcus
TB
MAC
PJP
CMV
EBV
viral illness

Sickle cell: __ MC cause of death (40% of deaths)

infection

Sickle cell: why do they get functional asplenia early in life?

recurrent episodes of splenic infarction

Sickle cell: which organisms particular at risk of due to functional asplenia?

encapsulated:
- S pneumo
- H influ

Prophylaxis for sickle cell disease kids: <5: with what abx?
- when to stop?

penicillin
no prior severe pneumoccocal infection or surgical splenectomy

What is the dose of prophylactic penicillin in kids <5?

125mg oral BID until 3y/14kg then 250mg oral BID after 3yo

Sickle cell: high risk criteria for bacterial infection

toxic appearance
temp >40
abn wbc of <5 or >30
noncompliance with penicillin prophylaxis

Sickle cell: at risk of __ osteomyelitis

salmonella

Sickle cell: if pt have temp >38, what labs?

- cbc
-retic count
-blood culture

Sickle cell: why is getting a retic count so important if temp >38?

parvo B19 can cause life thr aplastic crisis

Sickle cell: what typical infections can cause acute chest syndrome in sickle cell kiddos?

c pneumoniae
m penumoniae
RSV
S aureus
S pneumoniae

Sickle cell: low risk vs high risk pt with fever:

high adm for abx
low: typically ceftriaxone 50 mg/kg, and discharged to close outpatient follow-up. All patients should be reeval- uated within 24 hours or sooner if the clinical condition deteriorates. (sim tx for outpt febrile neutropenia oncology pt)

Sickle cell disease: osteomyelitis typical 2 sx:

fever
bone pain (N in sickle cell so can be difficult)

As OM can be difficult dx in children with sickle cell disease, what labs should they get?

CBC with diff
ESR
culture
consider bone scan/MRI
stool sample for salmonella

Congenital heart disease: what two infections concerning?

1. viral can cause diff in heart function
2. IE

IE in kids: typical bugs

- s aureus
-s viridans
- strep bovis
- enterococci
-HACEK: hemophilis, actinobacilis, nomyectemocomitans, cardiobacterium hominis, eikenelle, kingella

HACEK organisms

hemophilis, actinobacilis, nomyectemocomitans, cardiobacterium hominis, eikenelle, kingella

Children with suspected IE: labs

adm to hosp for echo
blood cultures
cbc
chem 7

Children with suspected IE: tx

abx - ceftriaxone 200mg/kg IV or IM q24h
or
vanco 10-20mg/kg IV q6-8h
for 4 weeks

Option for sh tx option in IE (ie 2 weeks of tx): abx combination?

ceftr 100mg/kg IV or IM q24h with gent 3-6mg/kg divided into IV q8h

VP shunt: fever with shunt - concern for?

shunt infection

VP shunt: if fever + AMS or meningismus signs - consult who and do what test?

neurosx
CSF sample

VP shunt: how to typically do a CSF sample if concerned for infection?

from shunt reservoir

VP shunt: infection of shunt 2 usual causative organisms?

s aureus
staph epidermidis

VP shunt: if AMS, what test?

CT to assess ventricle size

1. Which of the following are appropriate methods to obtain urine as part of a fever evaluation in a non-toilet-trained child?

a. Catheterizedspecimen
b. Clean catch, midstream

c. Suprapubicaspiration
d. A and C

2. A 38-day old male infant presents to the emergency department (ED) after parents noted a fever at home today. In the ED, the tem- perature was noted to be 40.0°C. The child was born at 35 weeks gestation and 1 week ago was diagnosed with otitis media by his primary care physician and has been taking amoxicillin as treat- ment. Which of the following historical aspects places this child at higher risk for invasive bacterial infection?

Downloaded for Tegan Turner (turnert5@myumanitoba.ca) at University March 10, 2024. For personal use only. No other uses without permission.

a. b. c. d. e.

Fever responsive to acetaminophen Temperature of 40.0°C
Prior treatment with antibiotics Prematurity

B, C, and D

3. Which of the following statements regarding occult bacteremia in children younger than 36 months old is true?
a. Children with no obvious source of fever and a temperature

higher than 102.2°F (39°C) have an incidence of bacteremia of 5%.

Most patients appear toxic.
The most common pathogen is Neisseria meningitidis.
There has been a marked decrease in the incidence of occult bac-

teremia since the advent of universal vaccination against pneu-

mococcus and Haemophilus influenzae type B.
With pneumococcal bacteremia, most patients remain febrile

until antibiotic therapy is initiated.

4. A 3-year-old boy presents with a fever of 103°F. His mother reports that the fever started approximately 5 days ago, and he has an associated maculopapular rash. On examination, you find the patient also has bilateral conjunctival injection, a strawberry tongue, and swelling of his hands and feet. Which of the following medications should be included in the treatment of this patient?

a. Aspirin
b. Decadron
c. PenicillinG
d. Ceftriaxone

A 2-year-old presents with a high fever and vomiting. On examina-

tion, you find an irritable child with a rectal temperature of 102°F rectal and a stiff neck. The patient’s past medical history is significant for hydrocephalus with a ventriculoperitoneal shunt placement. You suspect the patient has a ventriculoperitoneal shunt infection. Which of the following is the most likely bacterial pathogen?

a. Haemophilus influenzae
b. Neisseria meningitidis
c. Staphylococcusaureus
d. Staphylococcus epidermidis

161. Ped Fever Flashcards

(133 cards)