Management Of The Febrile Infant

Management of the Febrile Infant 2001 Theodore C. Sectish, MD Director, Residency Training Program in Pediatrics Assistant Professor in Pediatrics Stanford University School of Medicine

Learning Objectives: ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Historical Perspective ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Fever in Practice ,[object Object],[object Object],[object Object],1-Pantell Clin Pediatr 1980;19:77 2-Hoekelman AJDC 1979;133:1017

Diagnoses: Febrile Infants < 3 months ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Pantell, personal communication, PROS study

Fever without Source (FWS) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Definition of Fever ,[object Object],[object Object],[object Object],[object Object],[object Object],Baraff Pediatrics 1993;92:1

Bundling and Fever ,[object Object],[object Object],[object Object],[object Object],[object Object],Cheng TL Pediatrics 1993;92(2):238

Febrile Infants: Outcomes of Interest ,[object Object],[object Object],Jaskiewicz Pediatrics 1994;94:390 Bass Pediatr Infect Dis J 1993:12:466 Fleisher J Pediatr 1994;124:504 Jaffe NEJM 1987;317:1175 Baraff Pediatr Infect Dis J 1992;11:257 Pantell, PROS Study, personal communication

Serious Bacterial Infection (SBI) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Probability of Bacterial Infection in Febrile Infants, <90 Days of Age Baraff J Peds 1993;92:1

Probability of Occult Bacteremia: Febrile Infants, 3 - 36 months Baraff Pediatrics 1993;92:1 Lee Arch Pediatr Adolesc Med 1998;152:624

Outcomes of Occult Bacteremia in the Age of Hemophilus Baraff PIDJ 1992;11:146

Occult Bacteremia in the Post-HIB Vaccine Era: 3-36 months ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Lee Arch Pediatr Adolesc Med 1998;152:624

Outcomes of Outpatients with Pneumococcal Bacteremia ,[object Object],[object Object],[object Object],[object Object],[object Object],Bachur Pediatrics 2000;105:502

Reevaluation of Outpatients with Pneumococcal Bacteremia Bachur Pediatrics 2000;105:502

Conclusions ,[object Object],[object Object]

How Do Clinicians Evaluate Febrile Infants?

Evaluation of the Febrile Infant ,[object Object],[object Object],[object Object]

Evaluation of the Febrile Infant ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

What is “Toxic”? It is a very difficult task to define “toxic”; the closest I can come to a definition is to say that if to an experienced physician he looks and acts damned sick, he’s toxic. Sidney Gellis Pediatric Notes , 1979

Definition: “Toxic” Infant ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

1993 Clinical Practice Guideline ,[object Object],[object Object],[object Object],[object Object],Baraff Pediatrics 1993;92:1

Important Clinical Questions ,[object Object],[object Object]

Clinical Practice Guideline Low Risk Criteria: Clinical Appearance ,[object Object],[object Object],[object Object],[object Object]

Clinical Practice Guideline Low Risk Criteria: Laboratory Tests ,[object Object],[object Object],[object Object],[object Object],[object Object]

Guideline: 0 - 28 days ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Guideline: 29 - 90 days Follow-up ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Modified Guideline: 3 - 36 months

Modifications to the Guideline ,[object Object],[object Object],[object Object],[object Object],Baraff LJ Annals of Emerg Med 2000;36(6):602 Fleischer GR J Pediatrics 1994;124:504 Bass JW PIDJ 1993;12:466

Modified Guideline: 3 - 36 months Options ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Baraff LJ Annals of Emerg Med 2000;36(6):602

Modified Guideline: 3 - 36 months Options ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Baraff LJ Annals of Emerg Med 2000;36(6):602

Modified Guideline: 3 - 36 months Options ,[object Object],[object Object],[object Object],[object Object],Baraff LJ Annals of Emerg Med 2000;36(6):602

Guideline: 3 - 36 months Follow-up ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Quotable Quote: “I don’t consider these ‘rules.’ They are kind of…..like….‘guidelines’” John Prober, speaking about tournament rules at the 50th Birthday Golf Tournament for brother Charles. August 1999

Data Support Departures from the Guideline ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Adherence Rates with Guideline ,[object Object],[object Object],[object Object],[object Object],[object Object],Young, Pediatrics 1995;95:623

Otitis Media Influences Management ,[object Object],[object Object],[object Object],Young Pediatrics 1995;95:623

Data from Pediatric Practice: the PROS Fever Study ,[object Object],[object Object],[object Object],[object Object],[object Object],Personal communication, Pantell, PROS Study ,[object Object],[object Object],[object Object],[object Object],[object Object],3093 infants, < 3 months of age

PROS Fever Study: Laboratory Tests Personal communication, Pantell, PROS Study

PROS Fever Study: Management Personal communication, Pantell, PROS Study

Outcomes in PROS Fever Study Observed rates of: Bacteremia 1.5 % Bacterial meningitis 0.3% Of these: Treated at initial contact 96% Hospitalized at initial contact 84% Preventable bad outcomes 0% Personal communication, Pantell, PROS Study

PROS Fever Study: Adherence Rates to Guideline ,[object Object],[object Object],[object Object],[object Object],[object Object],Personal communication, Pantell, PROS Study

New Considerations ,[object Object],[object Object],[object Object],[object Object],[object Object]

Automated Blood Culture Systems ,[object Object],[object Object],[object Object],[object Object],McGowan KL Pediatrics 2000;106(2):251 Alpern ER Pediatrics 106(3):505

Band Count: Not Discriminatory ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Kuppermann Arch Pediatr Adolesc Med 1999;153:261

Importance of UTI ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],AAP Committee on Quality Improvement Pediatrics 1999;103:843

Recognizable Viral Syndromes ,[object Object],[object Object],Greenes Pediatr Infect Dis 1999;18:258

Why Do Clinicians not Adhere to the Clinical Practice Guideline? ,[object Object],[object Object],[object Object],[object Object]

Why Do Clinicians not Adhere to the Clinical Practice Guideline? ,[object Object],[object Object],[object Object],[object Object],[object Object]

Caveat ,[object Object],BMJ 1999;319:18

Management of Fever Without Source ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Charles Prober’s Golden Rules ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Keep up with the literature.. ..managing febrile infants is an ever changing topic

Management Of The Febrile Infant

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Management Of The Febrile Infant