Pediatric Febrile Illnesses =========================== þ Febrile Rashes see also traditional childhood exanthems - "Fifth Disease" = Erythema Infectiosum - Scarlatina - Staph Scalded Skin Syndrome - Toxic Epidermal Necolysis (TEN) - Roseola < 28 days, temperature > 38 rectal: full sepsis workup 29- 60 days: practice variable as to whether to LP Rochester criteria: Dagan, 1985/1988: can we manage low-risk babies without LP, admit, antibiotics high-risk: soft tissue, skeletal or purulent OM low-risk: fullterm, no hospitalization, no antibiotics: no LP or antibiotics included those not febrile including v/d. Did not break down by presence or absence of fever or by age, included those <28 days. No assessment of clinical criteria. True incidence of SBI not known, not reproducible in other populations. Boston criteria: Baskin et al 1992, 28-89 days, temp > 38, 503 infants Low risk: no antibiotics in 48H, no immunications, not allergic to B lacams, no other reason for admit, CSF WBC < 10, WBC < 20K, Dischared with Rocephin IM. 27 had SBI. Allowed urine dip, didn't count bands on CBC. No controls. Philadelphia Criteria: 1993, Baker at all, CHOP, >38.2l Yale obs score < 10, WBC < 15K, band < 0.2, ua < 10 WBC, CSF WBC < 8, .... Inpt +- antibiotics vs. home (reliable) Of 747 65 had SBI: 100% sensitive, NPI 100%. Repeated 18 months later, same results. RSV didn't matter for neonates, but for of 29- 60 days: often UTI, never meningitis or bacteremia, so if RSV positive, just need to do UA? + flu: still needs full sepsis workup. Outpatient Management without Antibiotics of Fever in Selected Infants M. Douglas Baker, Louis M. Bell, and Jeffrey R. Avner ABSTRACT Background In many academic centers it is standard practice to hospitalize all febrile infants younger than two months of age, whereas in community settings such infants are often cared for as outpatients. Methods We conducted a controlled study of 747 consecutive infants 29 through 56 days of age who had temperatures of at least 38.2 °C. After a complete history taking, physical examination, and sepsis workup, the 460 infants with laboratory or clinical findings suggestive of serious bacterial illness were hospitalized and treated with antibiotics. The screening criteria for serious bacterial illness included a white-cell count of at least 15,000 per cubic millimeter, a spun urine specimen that had 10 or more white cells per high-power field or that was positive on bright-field microscopy, cerebrospinal fluid with a white-cell count of 8 or more per cubic millimeter or a positive Gram's stain, or a chest film showing an infiltrate. The 287 infants who had unremarkable examinations and normal laboratory results were assigned to either inpatient observation without antibiotics (n = 148) or outpatient care without antibiotics but with reexaminations after 24 and 48 hours (n = 139). Results Serious bacterial illness was diagnosed in 65 infants (8.7 percent). Of these 65 infants, 64 were identified by our screening criteria for inpatient care and antibiotic treatment (sensitivity = 98 percent; 95 percent confidence interval, 92 to 100). Of the 287 infants assigned to observation and no antibiotics, 286 (99.7 percent) did not have serious bacterial illness. Only two infants assigned to outpatient observation were subsequently admitted to the hospital; neither was found to have a serious illness. Outpatient care without antibiotics of the febrile infants at low risk for serious illness resulted in a savings of about $3,100 per patient. Conclusions With the use of strict screening criteria, a substantial number of febrile one-to-two-month-old infants can be cared for safely as outpatients and without antibiotics. > 66 days: considered reasonable to get all labs except LP and if negative, send home.