CASE: You are working after hours and a young mother brings her 12 month old infant with fever 104 C
Should you admit this patient and perform an infectious workup or send the patient home with close surveillance?
In any given year, 15% of visits to the ED or urgent care by children under 15 years of age are children with fever. The vast majority of these children have self-limited viral infections. Yet serious illness is also manifested by fever in children and includes meningitis, sepsis, and pneumonia. With increasing rates of vaccination against hemophilus and pneumococcus, invasive infection and meningitis have been declining. The most common serious infections are pneumonia in the less than three month group of infants and urinary tract infection in infants older than 3 months. Red flags indicating serious illness include any of the following:
- Change in sensorium
- Changes in crying/moaning patterns
- Cyanosis
- Rapid breathing and shortness of breath
- Hypotension
- Signs of meningeal irritation
- Rashes esp petechial
- seizures
This past year, the American College of Emergency Physicians[1] have released an updated clinical policy on evaluation of the child under two years with fever. Their recommendations are summarized below:
Infants 1-3 months: consider lumbar puncture (LP) to rule out meningitis in infants 29-90 days and admitted to hospital for observation. Antibiotics are appropriate after LP until cultures are returned as negative
Children 2 months – 2 years: perform a chest radiograph in children with fever of at least 100.4F with no clear infection source but have cough, rales or hypoxia. Do not perform CXR in children with fever and wheezing and high probability of bronchiolitis. Consider performing urinalysis and urine culture especially in high risk children including girls under 1 year, uncircumcised boys, fevers lasting longer than 24 hrs. and no clear infection source. If there is a positive urinalysis (leukocyte esterase or nitrates) start antibiotics without waiting on results of urine culture. AAP recommends collecting urine samples through cauterization or suprapubic aspirate.
If the infant or child presents during the influenza season, consider performing rapid influenza testing.
If serious infection is strongly considered, the following age grouped antibiotics are recommended:
Under 1 month Ampicillin + gentamicin or cefotaxime
Over 1 month with urinary: cefotaxime or cefixime
1-3 months possible meningitis ceftriaxone
1-3 months (listeria/enterococcus) add ampicillin
3 months + pneumonia amoxicillin or azithromycin
[1] Annals of Emergency Medicine, May 2016; 67(5): 625-639