Fever without FocusAugust 17, 2015Jesse Thompson, MS3

Rules

The box in front of you contains 6 rewards

The top 5 scores at the end will chose from the box in order of their points

Read questions and point allocations carefully – yes they are biased values & there may be a penalty for wrong answers

Raise your hand to answer. Wait for the question to be read.

Volunteer Scorekeeper?

What is a fever?

Axillary 37.3oC

PO 37.5oC

PR/TM 38oC

1 point for all 3 values; -10 points if wrong

A kid crawls into the ER…

Bernard is a 2yo boy brought to the CHEO ED. You see mom in the hall before going in (without reading triage notes), and this is all she tells you:

“He’s got a fever and is really irritable & lethargic. He has been crying a lot but can’t seem to tell me what’s wrong.”

What is the first thing you want to do upon walking in to the room? (1-5 points depending)

Eyeball for clinical impression (quick ABC evaluation)

Vital signs

…

The rest of the history…

Intermittent fever for 5 days, unclear exact values

More sleepy than usual but still interactive and even playful at times

Crying a lot but consolable

Appetite decreased slightly, Vomited once this morning, last BM today and normal (no diarrhea)

Voiding normally as per parents

No congestion, cough, swelling, or rash

PMHx: 3 previous febrile episodes since birth saw 3 different docs “an antibiotic” each time cleared things up

FHx: N/C

The rest of the history…

Intermittent fever for 5 days, unclear exact values

More sleepy than usual but still interactive and even playful at times

Crying a lot but consolable

Appetite decreased slightly, Vomited once this morning, last BM today and normal (no diarrhea)

Voiding normally as per parents

No congestion, cough, swelling, or rash

PMHx: 3 previous febrile episodes since birth saw 3 different docs “an antibiotic” each time cleared things up

FHx: N/C

Any other questions?

Immunizations UTD

No allergies or medications

SHx: lives at home with mom and dad, no sick contacts, developmentally normal, birth history is N/C

Physical Exam

Vitals: T 39oC pr // HR 110 // RR 25 // BP 100/65

General: Alert & active, no distress, cheeks flushed, moving all 4 extremities well

HEENT: TMs clear, throat clear, no lymphadenopathy, no rhinorrhea, neck supple

CVS: Ns1s2, no EHS, no M, normal fem pulses x2, good perfusion

Resp: GAEB, no wheeze or crackles, no WOB

Abdo: SNT, BS present, no HSM or masses, sacral dimple present

GU: b/l descended testes, uncircumcised, no urethral discharge, small urethral caliber

Identify pertinent positives (1 point each; -1 each wrong)

Summary

2yo M with 5d hx intermittent Fo (Tmax 39oC in ED)

Fussy but consolable with decreased PO intake

Previously healthy aside from 3 previous febrile episodes that required antibiotics – no follow up

Exam revealed a healthy 2yo uncircumcised boy with sacral dimple

Differential Diagnosis?

What would we do if he was: 15 days old? 50 days old?

0-28days: Full septic workup incl. LP, BCx, UCx

28d-3mo: Rochester criteria, clinical impression to determine extent of workup

1 point each

Symptoms of UTI

0-3 MONTHS OLD: (2 points)

Nonspecific syptoms: Fo/hypothermia, Vx, Dx, jaundice, difficulty feeding, malodourous urine, FTT, irritability

3-24 MONTHS OLD: (2 points)

More focused: frequency, Fo, cloudy/malodourous urine

2-6 YEARS OLD: (2 points)

Usual UTI: frequency, urgency, dysuria, 2o enuresis, suprapubic/abdo/CVA tenderness

Risk Factors for peds UTI

Uncircumcised

Male (until 6-8 months old)

Not breastfed

Constipation: why? (1 point)

Dysfunctional void pattern

Recent Abx

Previous UTI

Catheters

FHx recurrent UTI

Recent sex

Diaphragm/spermicide use

No evidence: poor hygeine, bubble bath use, urethral caliber, or type of undergarments

5 points for 5 risk factors without any incorrect; -1 point for failed attempt

Risk Factor Details

Diagnostic criteria for UTI

Requires both urinalysis, AND culture suggesting infection

URINALYSIS: dip, microscopy, automated

Nitrites – clinical significance? (1-3 points, -1 if wrong)

Leukocyte esterase – clinical significance? (1-3 points, -1 if wrong)

What other information can be helpful on UA? (1-3 points) Bacteriuria (equivalent to >105 CFU/mL in Cx)

CULTURE: what # of CFU/mL qualifies for diagnostic criteria? (2 points)

>50,000 CFU/mL of a single urinary pathogen

2 points

Bernard

2yo M with 5d hx intermittent Fo (Tmax 39oC in ED)

Fussy but consolable and decreased PO intake

Previously healthy aside from 3 previous febrile episodes that required antibiotics – no follow up

Exam revealed a healthy 2yo uncircumcised boy with sacral dimple

Investigations for

Bernard?Approach by age first:

<28d, 1-3mo, or >3mo

+ At CHEO: CBC, BUN/Cr, lytes

Significance of sacral dimple? (2 points)

2-24mo with T>38o

Judged to need immediate Abx?

YES

Obtain urine for UA & Cx

NO

UTI likelihood <1%? (based on

RFs)

YES: Follow clinically (24-48h)

& R/A if fever persists

NO: UA only (collect for Cx if positive UA) OR

UA+Cx depending on clinical gestalt

How could we collect a sample?

Methods of collection (in order of reliability): (4 points)

1. Suprapubic aspirate

2. Catheterization (in/out)

3. Clean catch specimen

4. Urine bag

Why do a bag urine… ever?

1. UA can be done from bag urine sample

2. A negative bag culture does indeed RULE OUT infection!

2 answers, 2 points per correct answer; -2 points per wrong answer

Bernard’s U/A

Yellow cloudy urine

pH 6 (N 5-7)

No ketones, glu, bilirubin

No protein, trace blood

3+ Nitrites

2+ Leukocyte esterase

Describe this pattern (1-3 points; -3 if wrong)

1. Nitrites – likely gram negative organism in urinary tract (specific)

2. LE – pyuria suggests UTI (non-specific)

3. Overall: Based on +Nit and +LE, with clinical picture including fever… very likely (up to 90%) that Bernard has a gram negative UTI

U/A + microscopy

Yellow cloudy urine

pH 6 (N 5-7)

No ketones, glu, bilirubin

No protein

3+ Nitrites

2+ Leukocyte esterase, WBC 8/hpf

Trace blood, RBC 2/hpf

Many bacteria seen

Describe the pattern now (1-3 points)

WBC confirm pyuria (>5/hpf), and “bateriuria” is equivalent to >105 CFUs on Cx

Overall: increasing evidence for gram negative UTI

Potential Organisms?

Klebsiella

E. Coli (70%)

Enterococcus, Enterobacter

Proteus, Pseudomonas

Staph saprophyticus (rarely S. aureus)

3 points for 5 organisms

1 point for mentioning most common organism

Diagnostic Algorithm (3-

24mo)

Big 2 questions:

1. # risk factors (correlate with un/circumcised)?

2. UA/UCx results?

Diagnostic Algorithm (>24mo)

Big 2 Questions:

1. Uncircumcised?

2. Symptoms?

Antibiotics for Bernard? Wait for culture?

Empiric Abx stated immediately after collection of urine sample in children with both: Positive U/A, and Suspected UTI

Narrow Abx choice after culture results if necessary

How are we going to get his urine for culture? (1-2 points)

2 points

Specific Abx for Bernard?

@ CHEO: Ampicillin + Gent/Tobramycin

Alternatives available if allergies or hx renal disease Ceftriaxone? (1-3 points) Fluoroquinolones? (1-3 points)

What about MacroBID??? (1 point, 5 points if reasoning explained)

NO! Does not achieve therapeutic concentration in the blood which is too risky in infants

2 points, -1 if wrong

Route of Abx Administration?

IV = PO wrt efficacy!

Choose based on practicality Ability to take PO Availability of specific Abx Compliance/reliability Cost

3 points, -1 if wrong

Duration of Tx?

7-14 days 2 points, -1 if wrong

Other Investigations?

RBUS (renal/bladder ultrasound):

All febrile infants, looking for anatomic abnormalities, abscess, and hydronephrosis

During first 2 days of antibiotics ideally

What if RBUS is abnormal or this is a recurrent febrile UTI? 2 points

VCUG (voiding cystourethrogram):

Not recommended after 1st febrile UTI unless abnormality on RBUS, evidence of high-grade VUR, or recurrence of febrile UTI

2-4 points depending

What is Vesicouretal Reflux?

VUR = retrograde passage of urine from the bladder through the UVJ into the ureter Most common GU abN that leads to renal damage

Graded I-V: I: ureters only II: ureters and renal pelvis III: ureters and pelvis + minor dilatation IV: ureters, pelvis, and calyces fill + significant dilatation V: above plus major dilatation & tortuosity

Treatment: medical = surgical almost always Prophylactic Abx only beneficial in high grade

1-5 points

Admit to hospital if…

1. Age <2mo

2. Urosepsis: Toxic appearance, HoTN,…

3. Immunocompromised

4. IV needed: vomiting/inability to tolerate PO

5. Unreliable: lack of adequate follow-up

6. Dehydration

7. Failure of outpatient tx

1 point per correct, -1 for incorrectThere are 7 answers

What if...

What are we thinking now?

SICKLE CELL DISEASE: 8% of African descendants have HbS trait 0.2% HbSS, SC, or S-Bthal

Explain the pathophysiology (2-5 points depending) Hemoglobinopathy that decreases solubility of Hb in

blood precipitation (sickling) in conditions of hypoxia (ex. low pO2, dehydration, fever) infarction of tissues d/t capillary occlusion (spleen, lungs,

bones, brain, digits) hemolysis chronic well-compensated normochromic

normocytic anemia

2 points

When does SCD present?

Usually around 5-6mo old (fall in HbF)

Presentations (5 points for all 5): 1. Vaso-occlusive pain crisis

2. Neurological crisis

3. Acute chest crisis

4. Aplastic crisis

5. Acute splenic sequestration

Functional asplenia by ~5yo

UTI common in febrile kids w SCD – exacerbated risk of renal damage during UTI

2 points

Key management points of SCD

1. Support: O2, IVF

2. Analgesia

3. BS-Abx

(3 points)

Trivia for extra points

Most common 1st presentation of SCD? (1 point) Dactylitis

Does this UA suggest UTI?: Nitrite negative, LE 3+, blood trace, protein negative (1-3 points) Maybe – could be gram positive UTI, could be KD, could have

played a soccer tournament all weekend, etc.

Name the prophylactic abx & age ranges for SCD (2 points) Penicillin until 5yo

Screening investigations for SCD? (4 points!)1. TCD @ 2yo, q1y until 16yo

2. Retinal exam at 8yo, q1y

3. Hip radiographs at 10y, q1y

4. ECHO at 10yo, q2y

Objectives

Review sx and diagnostic criteria for UTI in children

Review UA – normal and abnormal variations in results according to age and collection method

Review possible etiologies/risk factors for UTIs in children

Review treatment, management, and follow-up for UTI

Review significance of fever in a child of African descent (SCD)

References

1. AAP. Clinical Practice Guideline. Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 months.

2. Pediatrics in Review. Urinary Tract Infections and Vesicoureteral Reflux in Infants and Children.

3. Pediatrics in Review. Sickle Cell Disease.

4. Toronto Notes

5. UpToDate

FINAL SCORES?!