New ED attending question

[unchartedem]

---

Members do not see this ad.

Hey everyone, I've tried searching for this answer but only found one old post. My question is as far as managing pediatric fever I have begun to manage it like this: 0-6 wks full sepsis work-up, 6 wks - 3 months I am basically using the rochester protocol. However what I don't understand is when it states that no focus of infection constitutes one of the criteria for low risk does that mean that if I have a well appearing infant, with normal birth and med history and normal labs , and I see cellulitis or I see PNA on a CXR that I then have to do an LP before I admit. It seems that if I end up finding a focus during my work-up and I'm not concerned about meningitis because the child is well appearing, then an LP seems kind of dumb. Am I thinking about this right. Would someone else shine some light on this or at least what they do or have seen people do with this?

 

[Gorymomimifit]

Thats a good question. I am curious to see what others will recommend. I am not a resident yet >.>

_____________________________________________

cna training

 

[Cuthbert]

Let's give the complete criteria and then discuss:

Rochester Criteria for Identifying Febrile Infants at Low Risk for Serious Bacterial Infection
--------------------------------------------------------------------------------
Infant appears generally well

Infant has been previously healthy:

Born at term (≥37 weeks of gestation)

No perinatal antimicrobial therapy

No treatment for unexplained hyperbilirubinemia

No previous antimicrobial therapy

No previous hospitalization

No chronic or underlying illness

Not hospitalized longer than mother

Infant has no evidence of skin, soft tissue, bone, joint or ear infection

Infant has these laboratory values:

White blood cell count of 5,000 to 15,000 per mm3 (5 to 15 × 109 per L)

Absolute band cell count of ≤1,500 per mm3 (≤1.5 × 109 per L)

Ten or fewer white blood cells per high-power field on microscopic examination of urine

Five or fewer white blood cells per high-power field on microscopic examination of stool in infant with diarrhea

Your question would be a toss up I think. You will get different answers from different doctors depending on how Type A they may be. Personally, I agree with you. If a child is older than 6 weeks and you have a focus of illness, you likely can treat that and be ok. I don't think any other physician would fault you on that.

However, in my opinion, you should always consider an LP with any type of infection (no matter what the focus) in a child younger than 2 months of age. Even if it is just an ear infection.

 

[J-Rad]

There's been a lot of movement and changes in the underlying thought processes behind treating FWLS in an infant. The 0-28 day old is generally easy, but the 1-3 monther gets more vague and artful. Truth be told, I am probably outdated in what I saw during my residency so I won't go too into it, but a well appearing five week old generally didn't get tapped where I trained (my peds ED training occurred where Stitch trained/worked). I'm really hoping the the little blue alien will weigh in with what he's seen for more recent practice patterns in a busy, urban peds ED.

 

[Stitch]

Good question and there's no right answer just now. The Rochester criteria (or Boston or Philly) only looked at infants 0-4 weeks, where everyone (currently) agrees the full work up is necessary. Beyond 4 weeks it can get controversial. And really where do you draw the line? What's the difference between a 33 day old and a 29 day old? Even a six week old I may not tap if they have fever and good follow up, but a five week old I probably will. If you had a cellulitis on a 3 months old who was vaccinated I probably wouldn't do an LP, but if he were 7 weeks? I might, it depends. I've found that I do fewer taps now than when I started and thought that EVERYONE needed a needle in their back.

Now, as to tapping when there is another obvious source. The main concern is that children don't opsonize very well. If there's an infection in one place, there's a risk that it will/has easily spread to other places. Think of your old nursing home grandma who has urosepsis. The most extensive data is on UTIs and the general feeling is that even with another source, like a URI, if a kid is febrile, they have around a 5% (ish) chance of having a concomitant UTI.

There was one study that looked at RSV positive infants and the rate of sepsis and they didn't find any incidence of meningitis but 6% also had UTIs. But you cannot extrapolate that data and say that the risk of meningitis is zero. So in general I check a lot of urines for infection.

Part of it also has to do with dispo. I'd have a lower threshold to admit a younger kid for pneumonia or cellulitis, and if I'm admitting them, then I'd probably talk to their pediatrician or the hospitalist and ask what they'd like to do. I doubt that anyone will ever fault you for tapping a kid automatically, and if you're sending them home consider the tap. What you don't want to get into is a partially treated meningitis because it's such a pain for everyone to deal with. You send the kid home on an antibiotic, then two days into his treatment he starts getting sicker and you wonder if you miss something.

So talk to your peds people, make sure they have good follow up, and you could go either way. When in doubt, tap, especially if you think parents are unreliable. Missing meningitis is a big litigation deal in peds. That was long, but maybe not so helpful.

 

[SurfingDoctor]

Like everyone said above, lots of debate with no clear cut protocol/guideline.

Though like J-Rad haven't done ER since residency, I personally have an issue with the age cut off. The immune function of a 6 week old is no different really than a 7 week old or a 4 week old or a 9 week old or a 12 week old. The only thing that really changes much in this time frame is the priming of the adaptive immune system to vaccinations. And even then, that is pretty poor (hence the need for so many boosters) but at least it's something. If you look at bacterial pathogens associated with illnesses in early life outside 1 month of age (which is usually GBS), H. Flu, Strep pneumo and E. coli are among the highest there. An infant at risk for SBI with the first two decreases with vaccinations. So I personally would follow whether a patient had been vaccinated along with clinical picture for a workup involving an LP, instead of using the strict criteria of 6 weeks or 60 days or whatever you use.

As a side, I can't remember seeing any pneumonia or cellulitis in a well appearing 6 week old with no leukocytosis. Even if you have a source on clinical exam, the child is unlikely well appearing, and with a poor functioning immune system, you really want to make sure you're treating everywhere that bacteria could have spread to. Just my two cents.

 

[emilykrys]

As a side, I can't remember seeing any pneumonia or cellulitis in a well appearing 6 week old with no leukocytosis. Even if you have a source on clinical exam, the child is unlikely well appearing, and with a poor functioning immune system, you really want to make sure you're treating everywhere that bacteria could have spread to. Just my two cents.

I would agree you would want to make sure you treat everywhere to make sure that the child doesn't redevelop it.

_____________________________________________
Ragnarok