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62. The Unvaccinated Febrile Child: No Shot, Too Hot!
Keywords
VaccinesUnvaccinatedFebrile ChildCase
Pertinent History
The patient is a 22-month-old female who presented to the emergency department (ED) with her mother following two days of fever of up to 103 °F (39.4 °C) orally at home. Her mother reported that she seemed more tired and has been eating less, but had continued to drink well at home. She had not had any upper respiratory tract infection symptoms, vomiting, diarrhea, abdominal pain, or rash. They reported that they just returned home from a trip to Disneyland last week. The patient’s mother was concerned because her child is always healthy and has never been sick despite being unvaccinated.
Pertinent Physical Exam
BP 98/40, Pulse 155, Temp 103.4 °F (39.7 °C), RR 32, SpO2 99%.
General: Alert, awake, comfortably held by parent, crying on physician approach.
Head, Eyes, Ears, Nose and Throat (HEENT): Nares without discharge, tympanic membranes clear, clear and moist oropharynx, and neck supple.
Pulmonary: Tachypnea with good aeration, no wheeze, rales, or rhonchi.
Cardiac: Tachycardia without murmur, warm extremities, and capillary refill <2 seconds.
Abdominal: Nontender, no mass, and no hepatosplenomegaly.
Skin: No rashes.
Pertinent Diagnostic Testing
Test | Result | Units | Normal range |
|---|---|---|---|
Urinalysis – Leukesterase | Positive | – | Negative |
Urinalysis – Nitrites | Positive | – | Negative |
Urinalysis – White Blood Cells | Positive | – | Negative |
Plan
Antipyretics (10 mg/kg of ibuprofen), oral cephalexin dose, and urine culture sent.
Updates on ED Course
The child tolerated ibuprofen, oral antibiotics, and a popsicle. After one hour, vitals were rechecked and had normalized. The patient was sent home with next day pediatrician follow-up, and return precautions were discussed with the family.
Learning Points: Serious Bacterial Infections
Priming Questions
1. In the unvaccinated child, how likely is a serious bacterial infection?
2. What is the epidemiology of serious bacterial infection in children?
3. What are the appropriate tests that should be performed in the Emergency? Department and what is the appropriate follow up?
Introduction/Background
- 1.
Fever is one of the most common reasons a child will present to the pediatric emergency department (ED) accounting for approximately 20% of all ED visits [1–3]. It is often a cause of parental worry and fear [4, 5].
- 2.
The etiology of fever in children is often difficult to determine and may be the only sign in infants and young children of serious bacterial infection [6]. In the well-appearing child, it is often challenging to determine the appropriate screening for safe discharge from the ED [3].
- 3.
There are substantiated guidelines for the ED workup of infants less than 3 months of age with fever. However, guidelines for children 3–36 months have yet to change dramatically after the widespread vaccination against Haemophilus influenza b (Hib) and Streptococcus penumoniae (Sp) . These vaccines have resulted in a significant decrease in rates of serious bacterial infections (SBI) and occult infection [7, 8].
Physiology/Pathophysiology/Epidemiology
- 1.
For the majority of well-appearing children presenting with fever without a source, the etiology for their symptoms will be a minor viral illness [9, 10]. Prior to vaccination development, Hib and Sp were both common causes of SBI in young children [11].
Since the introduction of the Hib vaccine in 1987, rates of invasive disease have fallen by 99% [12–14].
Since the introduction of the Sp vaccine in 2000, rates of invasive disease have fallen 75% [12–14].
Rates of occult bacteremia in the well-appearing child with fever without a source have decreased from as high as 10% to less than 0.5% for children aged 3–36 months. This reduction is also seen in undervaccinated children [3, 15].
- 2.
In the last 20 years, the epidemiology and cause of childhood SBI had changed. Urinary tract infection (UTI) is now the most common cause of SBI in children, including children without a source. [3, 16, 17] Whereas Sp used to be the predominant pathogen of infant bacteremia, E.coli now predominates [3, 14]. Now, 96% of all SBIs are attributable to pneumonia and UTI, with bacteremia only accounting for 0.14% [18].
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