Done by: Ala Rawashdeh,
Abdallah Ajarmah,
Abdallah Nsour
Supervised by Dr Marwan Alshalabi
Outline
Fever
Fever without localizing signs (FWLS)
Periodic fever
Familial Mediterranean fever
Fever
Fever, a physiologic response characterized by an elevation
of body temperature above normal daily variation.
Normal range of body temperature is 36.6-37.9°C rectally.
Fever is defined as a rectal temperature ≥38°C (100.4°F).
Hyperpyrexia = a value >40°C (104°F).
Body temperature assessment
Rectal: for 3 min
Most accurate
Measured reading - 0.5 °C
Oral: for 1 min
Axillary: for 3 min
Measured reading + 0.5 °C
Tympanic
Skin
• Fever Without a Focus
Refers to a rectal temperature of 38°C or higher
as the only presenting feature without other
presenting S&S.
There are 2 subcategories of fever without a
focus:
1. Fever without localizing signs (FWLS).
2. Fever of unknown origin (FUO).
Fever Without Localizing Signs
(FWLS)
Fever of acute onset with duration of <1 wk and
without localizing signs. It’s a common
diagnostic dilemma in children <36 months of
age.
The etiology and evaluation depends on the
age with 3 age groups considered:
1. Neonates or infants to 1 mo of age.
2. Infants >1 mo to 3 mo of age.
Fever is significant in this age group, because they have an
immature immune responses as well as that they display
limited signs of infection.
In general, neonates who have a fever and do not appear
ill have a 7% risk (and is heightened in the infant born prematurely) of having
a serious bacterial infection (SBI) which include:
UTI (MC)
Bacteremia Meningitis
Pneumonia Enteritis
Osteomyelitis Septic Arthritis
Etiology
Common pathogens in this age group
include:
1. Bacterial: GBS, E. coli & listeria
monocytogenes.
2. Perinatally acquired HSV infection.
Approach to febrile neonates
1. History and Physical examination
(unreliable physical signs)
2. Hospital admission
All febrile neonates should be hospitalized.
3. Investigations (Sepsis workup):
CBC with differential
Inflammatory markers (ESR/CRP)
Blood culture
Urine analysis & culture
LP (CSF analysis & culture)
Stool culture (in infants with diarrhea or stool containing
blood or mucus)
CXR
CSF Analysis should include:
1. Cell counts
2. Glucose
3. Protein
4. Gram stain and culture
5. HSV and enterovirus PCR.
4. Empirical intravenous Antibiotics
Combination antibiotics, such as ampicillin and
cefotaxime or ampicillin and gentamicin, are
recommended.
Acyclovir should be included if HSV infection is
suspected.
The majority of cases are viral and the have
seasonal variation.
In winter RSV and influenza A
In summer and fall enterovirus and parechovirus
But always consider bacterial infections
MCC of bacteremia in infants from 1-3 months:
E. coli, Group B Streptococcus followed by S. aureus
Pyelonephritis is the MCpresentation especially in uncircumcised infant
boys and infants with urinary tract anomalies.
Other bacterial diseases in this age group:
-UTI most common
-otitis media
- pneumonia
- omphalitis
-mastitis
Ill-appearing (toxic) febrile infant
hospitalization
cultures of blood, urine, and CSF
immediate parenteral antimicrobial
therapy
obtain urine studies (urine WBC, leukocyte
esterase, nitrite, and culture) for
all girls <24 mo
all boys <6 mo old
all uncircumcised boys <2 yr
all children with recurrent urinary tract
infection
Investigations for ill looking baby (sepsis workup)
After History , physical examination and admission →
1- CBC , ESR, CRP .
2- blood, urine, and CSF culture (take the samples before giving
antibiotics)
3- urinalysis. (Urinalysis may be negative in infants <2 mo. of age with
pyelonephritis)
4- chest x-ray (if respiratory symptoms are present)
5- Stool study (if has diarrhea)
+viral diagnostic studies
Manegmant of Ill-appearing (toxic) febrile infant
Immediate parenteral antimicrobial therapy
Ampicillin (L. monocytogenes and Enterococcus) plus either ceftriaxone or cefotaxime.
This regimen is effective against the usual bacterial pathogens causing sepsis, urinary tract
infection, and enteritis in young infants.
If meningitis is suspected, add vancomycin for possible penicillin-resistant S. pneumonia
If the infant looks well but has fever…
use the Rochester Criteria or similar criteria is used to determine
his risk for bacterial or viral infection as pyelonephritis may be
seen in well-appearing infants who have fever without a focus.
Investigations: CBC, with differential, CRP, Blood culture,
Urinalysis and culture
3-36 months of age
MCC are viral.
Also serious bacterial infections do occur (except for
the perinatally acquired infections.) ,MCC are S.
pneumoniae, N. meningitidis, and Salmonella .
H. influenzae type b (not seen commonly due to vaccine).
Important bacterial infections among children 3-36
months of age include otitis media, sinusitis, pneumonia,
enteritis, urinary tract infection, osteomyelitis, and
meningitis.
What suggests it’s a bacterial infection?
1) temperature ≥39°C (102.2°F)
2) WBC count ≥15,000/µL
3) elevated absolute neutrophil count
4) band count
5) erythrocyte sedimentation rate (ESR) or C-reactive protein
The higher the T° and WBC count the more it likely to be
bacterial
Child appearance
well Toxic
Temperature>39 Temperature<39 Full sepsis workup
Immunized Not immunized Virla infection Admit and start empirical antibiotic
1. order blood culture then
carefully observed without administering empirical
empirical administration of antibiotics
Manage as an outpatients
antibiotic OR without performing diagnostic
take a blood culture but tests or administering
without empirical antibiotic antimicrobial agents, only
therapy supportive treatment
Thank you
