Ver el código de «Pediatric fever of uncertain source»

==Background==
*Fever accounts for 30% of pediatric visits
*Children <3 months are immunocompromised (e.g. poor opsonization, poor IgG response to encapsulated bacteria, macrophage and neutrophil dysfunction, bone marrow insufficiency)
*Concern is for missing a serious bacterial infection (SBI)

===Epidemiology and Risk===
{| class="wikitable" 
| align="center" style="background:#f0f0f0;"|'''Age'''
| align="center" style="background:#f0f0f0;"|'''0-14 days'''
| align="center" style="background:#f0f0f0;"|'''14-28 days'''
| align="center" style="background:#f0f0f0;"|'''28-60 days (pre vaccine)'''
| align="center" style="background:#f0f0f0;"|'''28-60 days (post vaccine)'''
| align="center" style="background:#f0f0f0;"|'''60-90 days'''
| align="center" style="background:#f0f0f0;"|'''> 90 days'''
|-
| [[Meningitis]]/SBI Prevalence ||1/10||1/20||1/100||1/1000||1/1000-10,000||> 1/10,000
|}
*Serious bacterial illness (SBI) includes UTI, meningitis, pneumonia, bacteremia 
*7% of patients <2 years old with fever have [[pneumonia]], however the etiology (viral/bacterial) or even the presence of pneumonia has low inter-observer reliability even among pediatric radiologists<ref>ACEP's Clinical Policy on Pediatric Fever. Clinical Policy for Children Younger Than Three Years Presenting to the Emergency Department With Fever. Annuals of Emergency Medicine 2003 42. 530-545</ref>
*4% Prevalence of [[UTI]] with common other sources of fever ([[OM]], viral [[URI]], etc)<ref>ACEP's Clinical Policy on Pediatric Fever. Clinical Policy for Children Younger Than Three Years Presenting to the Emergency Department With Fever. Annuals of Emergency Medicine 2003 42. 530-545</ref>
*0.3% of previously well children aged 3-36 months who have a fever without a source will develop significant sequelae, 0.03% will develop sepsis or meningitis<ref>ACEP's Clinical Policy on Pediatric Fever. Clinical Policy for Children Younger Than Three Years Presenting to the Emergency Department With Fever. Annuals of Emergency Medicine 2003 42. 530-545</ref>

===Concomitant Respiratory Viral Infection===
*Relatively high coincidence of [[RSV]], [[enterovirus]], and [[paraflu]] with bacteremia (and UTIs), so positive lab test for these viruses should not change testing and management plan<ref>Greenes, D.S.M., & Harper, M. B.M. (1999). Low risk of bacteremia in febrile children with recognizable viral syndromes. Pediatric Infectious Disease Journal, 18(3), 258-261.</ref>
**[[RSV]]+ neonates aged 0-28 days, 3.7% were bactremic (and 6.1% had [[UTI]]s) 
**RSV+ infants aged 29-60 days, (5.5% had [[UTI]]s)
*There is a low coincidence of [[influenza]] with SBI, so postivie lab test for this virus may change testing and management plan (i.e. lower risk of concurrent bacterial illness)<ref>Greenes, D.S.M., & Harper, M. B.M. (1999). Low risk of bacteremia in febrile children with recognizable viral syndromes. Pediatric Infectious Disease Journal, 18(3), 258-261.</ref>

==Clinical Features==
*[[Acute fever|Febrile]]
**Defined as [[Celsius Fahrenheit Temperature Conversion|temperature]] ≥38°C (100.4°F). 
**Peripheral temperature is not clinically accurate and central measurements are the preferred means of determining fever.
**Parental report of confirmed fever at home (i.e. via thermometer), even with no fever in ED, has rates of SBIs high as 4.7% (0-28 day range)<ref>Serious bacterial infections in neonates presenting afebrile with history of fever Ramgopal S, Walker LW, Tavarez MM, et al. Pediatrics. 2019;144(2):e20183964.</ref>

==Differential Diagnosis==
{{Pediatric fever DDX}}

==Evaluation & Management==
*Preemies: Count age by estimated postconception date (not by actual delivery date) for 1st-90d

===0-7 Days===
''For all infants (toxic and well-appearing)''

{| class="wikitable"
|-
| '''Child Appearance''' 
| '''Work Up''' 
| '''Treatment''' 
| '''Disposition & Follow-up''' 
| '''Comments'''
|-
| '''Temperature ≥38°''' 
'''Toxic or Well'''
| 
*CBC 
*Blood cultures 
*[[Urinalysis]], Urine culture 
*[[LP]]-CSF 
*[[CXR]]
*+/- Stool studies (if diarrhea)
| 
{{Pediatric fever antibiotics 0-28)}}
| Admit 
| SBI incidence
*Ill appearing: 13%–21% 
*Not ill appearing: <5%
|}

{{Pediatric fever acyclovir indications}}

Note:
*CXR is optional if no resp sx and another source identified
*LP is necessary even if another source identified due to immature blood-brain barrier
*Do not give ceftriaxone to children <28d as may cause hyperbilirubinemia

===8-21 Days<ref>Evaluation and Management of Well-Appearing Febrile Infants 8 to 60 Days Old Robert H. Pantell, Kenneth B. Roberts, William G. Adams, Benard P. Dreyer, Nathan Kuppermann, Sean T. O'Leary, Kymika Okechukwu and Charles R. Woods; Subcommittee On Febrile Infants Pediatrics July 2021, e2021052228; DOI: https://doi.org/10.1542/peds.2021-052228 </ref>===
*For toxic infants, treat for sepsis and admit
*For well-appearing infants, see below algorithm
[[File:Peds fever 8-21 days (2.0).png|8-21 day algorithm]]

===22-28 Days<ref>Evaluation and Management of Well-Appearing Febrile Infants 8 to 60 Days Old Robert H. Pantell, Kenneth B. Roberts, William G. Adams, Benard P. Dreyer, Nathan Kuppermann, Sean T. O'Leary, Kymika Okechukwu and Charles R. Woods; Subcommittee On Febrile Infants Pediatrics July 2021, e2021052228; DOI: https://doi.org/10.1542/peds.2021-052228 </ref>===
*For toxic infants, treat for sepsis and admit
*For well-appearing infants, see below algorithm
[[File:Peds fever 22-28 days (2.0).PNG]]

===29-60 Days<ref>Evaluation and Management of Well-Appearing Febrile Infants 8 to 60 Days Old Robert H. Pantell, Kenneth B. Roberts, William G. Adams, Benard P. Dreyer, Nathan Kuppermann, Sean T. O'Leary, Kymika Okechukwu and Charles R. Woods; Subcommittee On Febrile Infants Pediatrics July 2021, e2021052228; DOI: https://doi.org/10.1542/peds.2021-052228 </ref>===
*For toxic infants, treat for sepsis and admit
*For well-appearing infants, see below algorithm
[[File:Peds fever 29-60 (2.0).PNG]]

===60 Days - 36 Months<ref>Jaskiewicz, J.A., McCarthy, C.A., Richardson, A.C., White, K.C., Fisher, D.J., Powell, K. R., et al. (1994). Febrile infants at low risk for serious bacterial infection-an appraisal of the Rochester criteria and implications for management. Pediatrics 94(3), 390-396.</ref>===
{| class="wikitable"
|-
| '''Appearance''' 
| '''Work Up''' 
| '''Treatment''' 
| '''Disposition & Follow-Up''' 
|-
| '''T≥38° + Toxic'''
| 
*CBC 
*Blood cultures 
*[[Urinalysis]], urine culture 
*[[LP]]-CSF 
*[[CXR]]^
| 
{{Pediatric fever antibiotics 90dy-36mo}}
| Admit 
|-
| '''T≥39°C + Well + Non-complete [[Prevnar]]'''
(No [[Prevnar]] or <4 weeks post 1st [[Prevnar]] dose)
| 
*[[Urinalysis]], Urine culture
*CBC 
*+/- CXR
| If WBC(+):
*[[Ceftriaxone]] 50mg-100mg/kg (also then consider [[blood culture]] and [[LP]], especially in <6mo old)
| Outpatient (24 hour follow-up)
|-
| '''T≥39°C + Well + [[Prevnar]]'''
(2 [[Prevnar]] or ≥4 weeks post 1st [[Prevnar]] dose)
| 
*Urine workup (UA, urine culture) for:
**Circumcised males <6 months
**Uncircumcised males <12 months
**All females
*+/- CXR
| Treat [[cystitis]] or [[pneumonia]] if postitive
| Outpatient (48hour follow up)
|-
| '''T≥38-38.9°C + Well'''
| Consider UA, CXR based on symptoms, etc
| Treat [[cystitis]] or [[pneumonia]] if positive
| Outpatient (48-72 hour follow-up)<ref>Baker, M.D., Bello, L.M., & Avner, J.R. (1993). Outpatient management without antibiotics of fever in selected infants. New England Jouranl of Medicine, 329(20), 1437-1441.</ref>
|-
|}
{{Pediatric fever CXR indications}}

*Non-UTI SBI incidence of <.4% in children >6 mo

==Low Risk Lab Criteria==
''If low-risk criteria below not met, then perform the LP (if not done) and admit for inpatient antibiotics''<ref> Smitherman, H.F. & Macias, C.G. (2014). Evaluation and management of fever in the neonate and young infant (less than three months of age) [Electronic Version]. UpToDate,Teach, S.J., Kaplan, SL, Wiley, JF.</ref><ref>Dagan, R. Sofer, S., Phillip, M., & Shachak, E. (1988). Ambulatory care of febrile infants younger than 2 months of age classified as being at low risk for having serous bacterial infections. Journal of Pediatrics, 112(3), 355-360.</ref>
===CBC===
*WBC 5-15 /mm<sup>3</sup>
*Absolute Band count <1500 /mm<sup>3</sup>
*Procalcitonin ≤0.5 ng/mL
*ANC ≤4000/mm<sup>3</sup>
===Urinalysis===
*Clear
*Neg Nitrate and Leukocyte esterase
*WBC <10/high powered field
===CSF===
*Studies should include WBC, protein, glucose, Gram stain, and culture for bacteria. Consider viral studies (HSV).
====0-28 days====
*WBC: 0-22/mm<sup>3</sup>
*Protein: <100mg/dL
====>29 days====
*WBC 0-7/mm<sup>3</sup>
*Protein: 15-25mg/dL

==Additional Management==
===Initial Empiric Antibiotics for Well-Appearing Infants===
{{Infant fever well antibiotics}}
{{Acetaminophen pediatric dosing chart}}

==See Also==
*[[Acute fever]]
*[[Fever of unknown origin (peds)]]
*[[Urinary tract infection (peds)]] 
*[[Sepsis (peds)]] 
*[[Meningitis (peds)]] 
*[[Febrile seizure]]
*[[PECARN Febrile Infant]]

==External Links==
*[http://www.pemed.org/blog/2011/10/9/fever-of-unknown-source-part-1.html PEM ED Algorithm for Pediatric Fever]
*[http://ddxof.com/pediatric-fever/ DDxOf: Pediatric Fever]

==References==
<references/>

[[Category:Pediatrics]]
[[Category:ID]]