Fever In Infants 28 Days Of Age
Fever in Infants 28 Days of Age:Emergency Department ManagementClinical Practice Guideline (CPG)Protocol approved by:Division of Pediatric Emergency Medicineand Infectious DiseasesDate of approval: 7/13cardinalglennon.comA
Fever in neonates (age 0 to 28 days)INCLUSION CRITERIA Infant 28 days of life Temperature 38 C (100.4 F) byany route/parental reportEXCLUSION CRITERIA Infants with RSVFebrile Infant 28 days oldIll appearing?YESFull Sepsis Evaluationand HSV EvaluationAmpicillin Cefotaxime*AcyclovirHSV ChecklistYES NO History of seizures Vesicles on skin/scalp CSF pleocytosis (CSF wbc 20/μL) Elevated transaminases History of maternal HSV History of maternal fever at L&D Thrombocytopenia Active Herpes in household contactNOFull Sepsis EvaluationRisk of HSV?(see checklist)All NO onchecklistDecision toevaluate for HSVbased on clinicaljudgmentAny YES on checklistAdmissionHSV EvaluationAmpicillinCefotaximeAmpicillin CefotaximeAcyclovirFull Sepsis Evaluation CBC with diff and Blood culture UA and Urine cultureAdmission CMP CSF Analysis and CSF cultureEmpiric Treatmento Infants 7 days : ampicillin 50mg/kg/dose every 8 hours,cefotaxime 50mg/kg/dose every 8 hourso Infants 7 days: ampicillin 50mg/kg/dose every 6 hours,cefotaxime 50mg/kg/dose every 6 hoursHSV Evaluation and Empiric Treatment CSF and Blood HSV PCR Nasopharyngeal, eye, rectal viral culture swabs Liver function tests (if CMP not done above) Acyclovir 20mg/kg/dose every 8 hours (if one or more ‘Yes’ on HSV Checklist)* Alternative therapy during Acyclovir shortage (and all ‘No” on HSV Checklist):Ganciclovir 6mg/kg/dose every 12 hoursAdmission
Objective: The purpose of the Febrile Neonate Clinical Practice Guideline is tostandardize care around the management of the febrile neonate without a focus ofinfection and at risk for serious infection.Target Population: Infants, 28 days of age or less, presenting with a fever ofunknown origin.Exclusions: Infants greater than 29 days of age, Infants without fever on exam or by history Infants with RSV bronchiolitisInclusion Criteria: Infants with temperature greater than or equal to 38.0 C by anyroute by healthcare worker or parental report Infants with gestational age less than 37 weeks, congenital medicaland/or surgical co-morbidities, and those hospitalized at any timesince birth are included in this guidelineTarget Users: Clinicians, nurses at Cardinal Glennon Children’s Medical CenterEmergency Department(ED) and inpatient units; primary care providers, andclinicians caring for infants in other EDs and urgent care centers.IntroductionAn infant with fever is a very common presentation to pediatric emergencydepartments, urgent care centers and primary care offices. The source of fever is notalways apparent and clinical exam alone cannot reliably predict serious illness inneonates and young infants. The most common cause of fever is usually a selflimited viral infection but the incidence of serious bacterial infections (SBI) may behigher in infants compared to older children, and neonates are even at a higher risk(Laupland et al. 2009).As many as 12% to 18% of all febrile neonates presenting to the pediatricemergency department have serious bacterial illness (Baker 1999, Kadish 2000,Maniaci 2008). Neonates are infected typically by more virulent bacteria such asgroup B Streptococcus, Escherichia coli, and Listeria monocytogenes. The mostcommon bacterial infections in this age group are UTIs and occult bacteremia(Baker 1999, Kadish 2000).Neonatal herpes simplex virus (HSV) is an important consideration in neonates asthey are more likely to experience serious sequelae from HSV meningitis. Riskfactors include primary maternal infection, cutaneous vesicles, seizures, CSFpleocytosis, and contact with household contact with active herpes. Acyclovir is notrecommended routinely for empiric treatment but should be considered in febrile
neonates with risk factors for neonatal HSV as early treatment may improveoutcomes (Kimberlin 2005).Assessment and DiagnosisClinical Assessment1. It is recommended that a rectal temperature be measured to establish fever 38 C (Claudius 2010).a. Infants who had a reliable rectal temperature measured at homeundergo the same evaluation as if the temperature was measured inthe office or ED (Claudius 2010).b. A response to antipyretic medication does not change the likelihood ofan infant having a serious bacterial infection (American College ofEmergency Physicians Clinical Policies Committee 2003).2. A thorough history, including questions about symptoms, sick exposures,infant birth history, maternal prenatal and intrapartum history, and physicalexam be obtained by the providerLaboratory StudiesRecommendations for an initial full sepsis evaluation of all febrile neonates include:a. Complete blood count with differentialb. Blood culturec. Urine analysis with microscopyd. Urine culture (catheter/suprapubic specimen)e. Cerebrospinal fluid (CSF) cell count with differential, protein and glucosef. CSF gram stain and cultureRadiology StudiesIt is recommended that a chest x-ray be performed in febrile neonates withrespiratory symptoms such as tachypnea ( 60 breaths/min), crackles in the chest,retractions, nasal flaring, cyanosis, or oxygen saturation 95% (NationalCollaborating Centre for Women’s and Children’s Health 2007).ManagementBecause of the high rates of SBI, it is recommended that all febrile neonates shouldreceive intravenous (IV) antibiotics and be admitted to the hospital (Ishimine 2007).
Medication: IV ampicillin plus a 3rd generation cephalosporin or gentamicinpending culture results.DrugAmpicillinRouteIV, IMDoseInfants 0-7 days: 50mg/kg/dose every 8 hoursInfants 8-28 days: 50mg/kg/dose every 6 hoursCefotaximeIV, IMGentamicinIV, IMInfants 0-7 days: 50mg/kg/dose every 8 hoursInfants 8-28 days: 50mg/kg/dose every 6 hoursInfants 0-30days: 4 mg/kg/day every 12-24 hours**adjust doses based uponmeasured serum peak and trough levels.Treatment of the neonate with a positive blood, urine or CSF culture should betailored to the bacteria identified and the infection site.HSV Risk Factors, Evaluation and ManagementNeonatal HSV has significant morbidity and mortality if untreated. The risk ofneonatal HSV approaches that of bacterial meningitis in the second week of life.Clinicians should have a high index of suspicion, and HSV testing and empirictreatment is recommended for neonates with following risk factors (Caviness et al.2008):a.b.c.d.e.Ill or septic appearing, hypothermia, severe respiratory distressSeizures (or history of seizure)Herpetic lesions/vesiclesCSF pleocytosis for age (white blood cell count 20/µL)Elevated AST and/or ALT on previous labs obtainedAdditional factors that may increase the risk of HSV over the general population(Caviness et al. 2008):a. Known maternal HSVb. Thrombocytopeniac. Maternal fever at labor and deliveryd. Close contact with a person with active herpetic lesionsLaboratory testing:a. Cerebrospinal fluid and blood HSV polymerase chain reaction (PCR)b. Nasopharyngeal, eye, and rectal viral culturesc. Liver function tests
ManagementIn addition to IV ampicillin and cefotaxime, empiric treatment of suspected HSV isrequired.- Acyclovir IV 4 mg/kg/day every 12-24 hours- Alternative regimen to IV acyclovir should be considered when there isnational shortage or depleted hospital supplies. In this setting, IV acyclovirshould be reserved for neonates with any positives on the HSV checklistand/or proven HSV disease.- First line alternative therapy: Ganciclovir IV 6 mg/kg/dose every 12 hoursReferences:Children’s Mercy Hospitals and Clinics, Evidence Based Practice Guideline, Febrile Infant.http://www.childrensmercy.org/Health Care Professionals/Medical Resources/ClinicalPractice Guidelines/Febrile Infant/Febrile Infant/American College of Emergency Physicians Clinical Policies Committee: Clinicalpolicy for children younger than three years presenting to the emergencydepartment with fever. Annals of Emergency Medicine, 2003; 42(4): 530-43Baker MD, Bell LM. Unpredictability of serious bacterial illness in febrile infantsfrom birth to 1 month of age. Arch Pediatr Adolesc Med. 1999;153(5):508–11.Caviness AC, Demmler GJ et al. Clinical and laboratory features of neonatal herpessimplex virus infection: a case control study. Pediatric Infectious Disease Journal,2008; 27(5): 425-30.Claudius I, Baraff LJ. Pediatric emergencies associated with fever. EmergencyMedicine Clinics of North America, 2010; 28(1): 67-84.Ishimine P. The evolving approach to the young child who has fever and no obvioussource. Emergency Medicine Clinics of North America. 2007; 25(4): 1087-115.Kadish HA, Loveridge B, Tobey J, et al. Applying outpatient protocols in febrileinfants 1-28 days of age: can the threshold be lowered? Clin Pediatr, 2000;39(2):81–8.Kimberlin DW, Whitley RJ. Neonatal herpes: what have we learned. Seminars inPediatric Infectious Diseases. 2005;16(1):7-16.
Laupland KB, Gregson DB, Vanderkooi OG, et al. The changing burden of pediatricbloodstream infections in Calgary, Canada, 2000-2006. Pediatric Infectious DiseaseJournal, 2009 28(2): 114-7.Maniaci V, Dauber A, et al. Procalcitonin in young febrile infants for the detection ofserious bacterial infections. Pediatrics. 2008;122(4):701-10National Collaborating Centre for Women’s and Children’s Health. Feverish illness inchildren: assessment and initial management in children younger than 5 years.National Institute for Health and Clinical Excellence (NICE) 2007: London (UK).
Infants, 28 days of age or less, presenting with a fever of unknown origin. Exclusions: Infants greater than 29 days of age, Infants without fever on exam or by history . route by healthcare worker or parental report Infants with gestational age less than 37 weeks, congenital medical and/or surgical co-morbidities, and those hospitalized at .
Fundations Pacing Guide. Level 1 . MP Units Unit TOTAL* Cumulative TOTAL** MP1 Unit 1 15 days 15 days MP1 Unit 2 10 days 25 days MP1 Unit 3 10 days 35 days MP1 Unit 4 10 days 45 days MP1 FLEX DAYS 3 days 48 days MP2 Unit 5 5 days 53 days MP2 Unit 6 15 days 68 days MP2 Unit 7 15 days 83 days
Practice Physical Exam New Patient Appointment Routine Follow-Up Windham Family Practice 14 days 32 days 5 days Brattleboro Family Medicine 33 days 32 days 23 days Maplewood Family Practice 38 days 32 days 9 days Putney Family Health 46 days 32 days 15 days Brattleboro Internal Medicine 19 days 32 days 15 days Just So Pediatrics 30 days 60 days .
African swine fever is an important viral disease of pigs that has become a serious threat to worldwide pork production since 2007. African swine fever virus . Iran, though there are no other reports indicating its presence in the Middle East. Etiology African swine fever results from infection by African swine fever virus (ASFV),
Keywords: Fever of unknown origin, Follow-up, Diagnosis Background In 1961, Petersdorf and Beeson formally proposed the definition of classic fever of unknown origin (FUO) by observing and summarizing a series of patients with unex-plained fever as follows: a temperature 38.3 C on several occasions over a period of more than 3weeks without a
Fever of unknown origin (FUO) According to a report by Petersdorf and Beeson published in 1961, the criteria for FUO are as follows: (i) a duration of fever 3 weeks, (ii) a temperature higher than 38.3oC on several occasions, and (iii) undiagnosed after 1 week of inpatient examination1. Namely, FUO is a fever
Chocolate Fever Chapter 11 Review 1. How did Mr. Cane know a cure for chocolate fever? a. He read about the cure in a book. b. He had chocolate fever as a kid. c. He was a doctor. 2. What did Mr. Cane look like? 3. What was the nickname of Alfred Cane? 4. What did Mr. Cane’s office look like? a. empty except for his desk b. fancy with leather .File Size: 251KB
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Further, the standard called for the utilization of third party certification as a mechanism for verifying compliance to the standard at the firm level. Despite the rapidly growing popularity of ISO 14001 there have been many criticisms regarding the ability of ISO 14001 to truly illustrate the day to day practices within a firm and the authenticity of its commitment to decreasing its .
