Fever without Focus August 17, 2015 Jesse Thompson, MS3.
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Transcript of Fever without Focus August 17, 2015 Jesse Thompson, MS3.
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?!