Fever Without Focus (Fwf) 2020 PDF

FEVER WITHOUT FOCUS  Objectives At end of this lecture ,the students should know the following: Definition of FWF How assess infants with fever? How to identify the risk group? How manage child with FWF? Definitions Fever without focus is defined as the acute onset of fever (rectal...

FEVER WITHOUT FOCUS  Objectives At end of this lecture ,the students should know the following: Definition of FWF How assess infants with fever? How to identify the risk group? How manage child with FWF? Definitions Fever without focus is defined as the acute onset of fever (rectal temp > 38C) (less than 1 wk) in an acutely ill, nontoxic- appearing child (aged less than 36 month) in whom no probable cause for the fever is evident after a careful history and physical examination. Other terms  Fever without source (FWS)  Fever without localizing signs(FWLS)  Almost one-half of previously healthy children 3 to 36 months of age with fever ≥39°C have no infectious source identified on physical examination but are at significant risk for occult bacteremia..  The majority of children who are well-appearing and have no identifiable source of infection have a self-limited viral illness. noninfectious etiologies for fever: Immunization reactions are the most frequent source of noninfectious fever in children 3 to 36 months of age Kawasaki disease, drug fever, malignancy (eg, leukemia), and chronic inflammatory conditions.  Serious Bacterial Infection (SBI):. urinary tract infection Pneumonia meningitis bacteraemia septicaemia bone and joint infection..  Children at higher risk of serious bacterial infection :include Infants under 3 months of age with temperature ≥38°C. Infants aged 3-6 months with temperature >39°C. children aged 6-36 months who are not fully immunised or appear unwell. WBC count ≥15,000/?L, and elevated absolute neutrophil count, erythrocyte sedimentation rate, or C-reactive  1.Age is the first factor to consider in a child with fever. The probability of presenting a serious bacterial infection is greater 1.Age. The probability of a serious bacterial infection is greater in children younger than 3 months. the rate of SBI increases with decreasing age ( 13-25% age 0-4 weeks, 8% age 4-8 weeks, 2 to 12% children aged 3-36 months. A in children younger than 3 months (2-3 %) and especially in children under 1 month.  2.Height of temp: Severe bacterial infections are more frequent with temperatures above 39 ° C. However, many viral infections also occur at temperatures between 39 °C and 40 °C. Temperature greater than 40 °C and especially 40.5 °C is more typical of bacterial infections.  3.White blood cell count (WBC) is generally not very useful for detecting or ruling out a serious bacterial infection.. WBC greater than 15,000 or less than 5,000/mm3 are considered risk factors for occult bacteremia. A total leukocyte count above 20,000/mm3 suggests an increased risk of occult pneumonia.  4.Elevations in levels of inflammatory mediators. procalcitonin (PCT). ≥0.5 ng/mL Serum PCT has better diagnostic accuracy for invasive bacterial illness (bacteremia or meningitis) in children with fever without a source compared with WBC or ANC PCT levels rise in response to bacterial infections more rapidly than those of CRP. A CRP level > 150 mg/l is useful as a marker of bacterial infection. CRP values 48 hours) Patients with signs or symptoms of UTI.  Lumbar puncture Indications: younger than 1 month all infants aged 1–3 months who appear unwell or WBC greater than 15,000 or less than 5,000/mm3. for young infants (three to six months of age) with group B Streptococcus bacteremia OR have neurologic signs.  chest x-ray should be considered in: 1. highly febrile children (temperature >39°C ) with leukocytosis (WBC count >20,000/mm3) , because of the strong association between leukocytosis and pneumonia. 2.infants under 3 months of age only if respiratory signs are present. SBI  meningitis Around 15% of cases of invasive meningococcal disease may present as fever without focus (FWS), basically in children aged 3 months to 3 years.  pneumonia The diagnosis of pneumonia in the pediatric population remains challenging. Despite its common occurrence, accurate diagnosis of bacterial pneumonia is difficult because : most lower respiratory tract infections are viral in etiology. findings on routine chest radiographs are nondiagnostic. blood cultures are rarely positive. obtaining sputum/ pleural fluid aspirates for etiologic diagnosis is impractical.  pneumonia The absence of cough or respiratory signs (tachypnea, retractions, nasal flaring, pulse oximetry 0.5 ng/mL, WBC ≥15,000/microL, and/or ANC ≥10,000/microL Should receive parenteral antibiotic therapy pending blood and urine cultures. Ceftriaxone (50 mg/kg intramuscularly) is preferred. Once these patients receive parenteral antibiotics, they may be discharged with assured follow-up within 24 hours and again at 48 hours to reevaluate for progression of illness. Unimmunized or incomplete immunization 2.Normal blood and urine studies : should not receive antibiotics and may be followed as outpatients. Their caregivers should be instructed to seek medical attention promptly if: The child looks sicker (eg, difficult to arouse, gray or cyanotic appearance) The child develops signs of dehydration. Signs of localized or systemic bacterial infection appear (eg, cough with tachypnea or difficulty breathing, cellulitis, or petechial rash) Temperature ≥40.5.  Completely immunized 1.Positive urine dipstick or urinalysis – Children with an abnormal urinalysis (positive nitrites or leukocyte esterase on urine dipstick, pyuria, or bacteriuria should receive empiric treatment for a UTI. 2. Urine dipstick or urinalysis normal or not performed –should be discharged home. Infants less than 1 month of :age Neonates who experience fever without focus are a challenge to evaluate because they display limited signs of infection, making it difficult to clinically distinguish between a serious bacterial infection and self-limited viral illness. Owing to the unreliability of physical findings and the presence of an immature immune system, all febrile neonates should be: hospitalized. Take bl. ,urine, CSF culture, with other septic screen. Combined antibiotic of ampicillin and cefotaxime is recommended. & may be Acyclovir.  :Infants 1-3 months of age If child is unwell or toxic: A. Admit. B. Investigations -: CBc with differential and CRP Blood culture Urinalysis and culture (SPA/catheter) Lumbar puncture Chest X-ray C. give AB Ampicillin) plus either ceftriaxone or cefotaxime is an effective initial antimicrobial regimen.  If child is well and normal wbc (5-15,000) ,normal urine exam.,normal cxr. Just observe for 24 hr without AB  Admission & Discharge Criteria Any infant 1-3 months of age with fever without source who is identified as high-risk clinically (appears unwell or toxic) or by laboratory data (WCC >15 000 or 20,000 irrespective of symptoms Consider lumbar puncture, especially in children younger than a year of age who appear unwell (meningism can be unreliable in this age group). Children in this category who appear stable after a period of observation in the outpatient setting may be managed with a single dose of parenteral antibiotics (such as ceftriaxone 50mg/kg IV/IM) with discharge and review by a primary care provider within 24 hrs.