Fever of Unknown Origin - Fever is one of the most common symptoms that causes the child to be taken to the doctor (19% -30% of the reason for the visit) .1 The definition of fever here is rectal temperature ≥ 380C in infants (children ≤ 1 year) .2,3 In children ≥ 1 the year the definition is rectal temperature ≥ 38.40C or oral (mouth) ≥ 37,80C.3
5% -20% of children with fever do not have a clear source of infection, even after a history of disease has been investigated and a physical examination is performed.1,4 Of these 20%, most are associated with viral infections that will heal by themselves.1,3, 4 Another important reason for under 2 years of age is UTI (3% -4% in boys and 8% -9% in girls).
However, in a minority of children, a fever of unknown origin (FUO) may be based on the presence of bacteria in the bloodstream that, if improperly handled, can cause severe bacterial infections such as pneumonia (infections of the lungs), osteomyelitis ( bone infection) and meningitis (infection of the lining of the brain) .2,3,4 Therefore, FUO treatment is very important to know, especially for children under 3 years old where this is quite common.
History of Disease and Physical Examination
The most important thing to do in dealing with FUOs is to recognize whether the child appears fine, sick, or toxic.5 What is meant by toxic is a pale or bluish state, with rapid, difficult, and lethargic breath and pulse children can not interact with people or objects around them, neither recognize the elderly, nor decrease eye contact) .2,6
A perfectly fine child has only a <3% chance of a serious bacterial infection. Sick-looking children have a 26% chance, and toxic-looking children have a 92% chance of severe bacterial infection.5
Symptoms or signs that may indicate a particular cause of fever should be investigated. For example a child's history tugging at his ears (otitis media), cough (respiratory problems), vomiting / diarrhea (gastrointestinal problems), or crying during urination (UTI) .5
In addition, child health history should also be considered, for example the following things:
Children with chronic diseases that lower the immune system (such as leukemia, HIV, diabetes, or congenital heart defects) require more aggressive FUO treatment.2
Children who have just taken antibiotics also need more aggressive treatment because these children tend not to look sick.
One more thing to note is whether the child is living his days in day care. Children who are entrusted in day care and often have otitis media have a greater risk of developing pneumonia.
Handling
The most important handling basis is whether the child appears to be toxic or not.
All 3-year-old children who appear toxic should undergo hospitalization to investigate the possibility of sepsis (bacteria in the bloodstream) or meningitis.6
FUO treatment that did not appear toxic was divided into 3 by age group: <28 days, 28-90 days, and 3-36 months.
Baby <28 days
In this age group, all those with fever should undergo evaluation at the hospital.6 Examinations undertaken are: 3
Blood count (erythrocytes / red blood, leukocytes / white blood and the types, platelets)
Blood cultures
Urine examination and culture (via catheter or suprapubic puncture)
Lumbar puncture for cerebrospinal fluid analysis and culture (from the spine)
Culture and examination of feces
X-ray chest
It is also given antibiotics.
Recently many experts suggest that antibiotics and hospital treatment should be performed only in infants with FUOs <7 days.3,6 In infants between 7-28 days who meet low-risk criteria for severe bacterial infections, treatment can be done with the above examination without being followed by antibiotics. The baby is observed until the above examination results are obtained. If bacterial culture is negative, the infant does not require antibiotics and can be observed at home with a note:
Parents can observe the baby closely
There is easy access to medical services
And guaranteed follow-up of the baby
Included in the low risk criteria are as follows: 2.6
Rochester Criteria to Identify Low Risk of Bacterial Infections in Infants Aged <90 days with FUO:
Baby looks fine
Previous baby always in good health:
Born enough months (≥ 37 weeks gestation)
No history of antibiotics before, during, and after birth
No history of treatment of hyperbilirubinemia (yellow / jaundice) without cause
There is no hospitalization history
There is no chronic or congenital disease
Not hospitalized longer than mother
There is no evidence of skin infection, soft tissue, bone, joints, or ears
Laboratory results:
White blood cells 5,000-15,000 per mm3
Calculate stem cells (one type of white blood cell) 1.500 per mm3
≤10 white blood cells per large field of view (LPB) on microscopic urine examination
≤ 5 white blood cells per LPB on infant microscopic stool examination with diarrhea
Antibiotics used for this age group are: 3
Ampicillin 100-200 mg / kg / day intravenously in divided doses every 6 hours and gentamicin 7.5 mg / kg / day in divided doses every 8 hours
Or ceftriaxone, 50 mg / kg / day in 1 dose
Or cefotaxime, 150 mg / kg / day in divided doses every 8 hours
Baby 28 - 90 days
In this age group, infants are also grouped in low risk or high risk with the Rochester Criteria above. If the baby has a high risk, then in addition to a complete examination, also given antibiotics
If infants fall into the low risk category, then there are 2 choices. The first is to do blood culture, urine, lumbar puncture, and antibiotics in the hospital. The second option is to do urine culture and observation without antibiotics unless the culture results are found to be positive. Regardless of the choice, follow-up evaluation should be done within 24-48 hours.2,3 The decision to observe at home or hospital returns to parents' ability to observe carefully, facilitate access to health services, and ensure follow- up.
Selected antibiotics are the same as the age group <28 days.3
Child 3 - 36 months
In this age group, the first one was to cluster whether the fever of the child was <390C or ≥ 390C.2,3,6
Fever <390C
What should be done is a careful history of the disease and physical examination to try to locate the cause of fever.2 Generally, no laboratory examination and antibiotics should be performed if the child appears to be well, given antipyretics. However the parent or caregiver should bring the child back if the fever continues within 2-3 days or if the condition of the child worsens.
Fever ≥ 390C
The latest recommendations for this group are: 2,3,6
Urine culture in all children <2 years of antibiotics prescribed
Chest x-ray in children with shortness of breath, rapid breathing rate, ronkhi (abnormal sound when examined by stethoscope), decreased breathing sound, or oxygen saturation (with oximeter) <95%. Also in children without these symptoms who have leukocytes> 20.000 / mm3
Stool culture if there is mucus or blood in the stool, or there are> 5 leukocytes per LPB on examination of microscopic stool
Blood cultures
There are several opinions on this subject. The first opinion is to do blood culture in all children with fever ≥ 390C. The second opinion is to do it only in children with fever ≥ 390C and leukocytes> 15.000 / mm3. The third opinion does so only in children with fever ≥ 390C and leukocytes> 18,000 / mm3. While a fairly new opinion emphasizes the number of neutrophils (one type of leukocytes, consisting of rods and segments). If neutrophils ≥ 10.000 / mm3, new blood cultures are done.
Giving antibiotics
Antibiotics are given by the same criteria as determining whether or not a blood culture is needed. Administration of antibiotics may also be considered if parents or caregivers are not reliable for follow-up evaluation.
The antibiotics selected were ceftriaxone, 50 mg / kg / day in a single dose or cefuroxime, 150-200 mg / kg / day in divided doses every 6-8 hours.
Follow-up in 24-48 hours
To see febrile treatment algorithms without any obvious cause in children <3 years, please refer to source number 2.
5% -20% of children with fever do not have a clear source of infection, even after a history of disease has been investigated and a physical examination is performed.1,4 Of these 20%, most are associated with viral infections that will heal by themselves.1,3, 4 Another important reason for under 2 years of age is UTI (3% -4% in boys and 8% -9% in girls).
However, in a minority of children, a fever of unknown origin (FUO) may be based on the presence of bacteria in the bloodstream that, if improperly handled, can cause severe bacterial infections such as pneumonia (infections of the lungs), osteomyelitis ( bone infection) and meningitis (infection of the lining of the brain) .2,3,4 Therefore, FUO treatment is very important to know, especially for children under 3 years old where this is quite common.
History of Disease and Physical Examination
The most important thing to do in dealing with FUOs is to recognize whether the child appears fine, sick, or toxic.5 What is meant by toxic is a pale or bluish state, with rapid, difficult, and lethargic breath and pulse children can not interact with people or objects around them, neither recognize the elderly, nor decrease eye contact) .2,6
A perfectly fine child has only a <3% chance of a serious bacterial infection. Sick-looking children have a 26% chance, and toxic-looking children have a 92% chance of severe bacterial infection.5
Symptoms or signs that may indicate a particular cause of fever should be investigated. For example a child's history tugging at his ears (otitis media), cough (respiratory problems), vomiting / diarrhea (gastrointestinal problems), or crying during urination (UTI) .5
In addition, child health history should also be considered, for example the following things:
Children with chronic diseases that lower the immune system (such as leukemia, HIV, diabetes, or congenital heart defects) require more aggressive FUO treatment.2
Children who have just taken antibiotics also need more aggressive treatment because these children tend not to look sick.
One more thing to note is whether the child is living his days in day care. Children who are entrusted in day care and often have otitis media have a greater risk of developing pneumonia.
Handling
The most important handling basis is whether the child appears to be toxic or not.
All 3-year-old children who appear toxic should undergo hospitalization to investigate the possibility of sepsis (bacteria in the bloodstream) or meningitis.6
FUO treatment that did not appear toxic was divided into 3 by age group: <28 days, 28-90 days, and 3-36 months.
Baby <28 days
In this age group, all those with fever should undergo evaluation at the hospital.6 Examinations undertaken are: 3
Blood count (erythrocytes / red blood, leukocytes / white blood and the types, platelets)
Blood cultures
Urine examination and culture (via catheter or suprapubic puncture)
Lumbar puncture for cerebrospinal fluid analysis and culture (from the spine)
Culture and examination of feces
X-ray chest
It is also given antibiotics.
Recently many experts suggest that antibiotics and hospital treatment should be performed only in infants with FUOs <7 days.3,6 In infants between 7-28 days who meet low-risk criteria for severe bacterial infections, treatment can be done with the above examination without being followed by antibiotics. The baby is observed until the above examination results are obtained. If bacterial culture is negative, the infant does not require antibiotics and can be observed at home with a note:
Parents can observe the baby closely
There is easy access to medical services
And guaranteed follow-up of the baby
Included in the low risk criteria are as follows: 2.6
Rochester Criteria to Identify Low Risk of Bacterial Infections in Infants Aged <90 days with FUO:
Baby looks fine
Previous baby always in good health:
Born enough months (≥ 37 weeks gestation)
No history of antibiotics before, during, and after birth
No history of treatment of hyperbilirubinemia (yellow / jaundice) without cause
There is no hospitalization history
There is no chronic or congenital disease
Not hospitalized longer than mother
There is no evidence of skin infection, soft tissue, bone, joints, or ears
Laboratory results:
White blood cells 5,000-15,000 per mm3
Calculate stem cells (one type of white blood cell) 1.500 per mm3
≤10 white blood cells per large field of view (LPB) on microscopic urine examination
≤ 5 white blood cells per LPB on infant microscopic stool examination with diarrhea
Antibiotics used for this age group are: 3
Ampicillin 100-200 mg / kg / day intravenously in divided doses every 6 hours and gentamicin 7.5 mg / kg / day in divided doses every 8 hours
Or ceftriaxone, 50 mg / kg / day in 1 dose
Or cefotaxime, 150 mg / kg / day in divided doses every 8 hours
Baby 28 - 90 days
In this age group, infants are also grouped in low risk or high risk with the Rochester Criteria above. If the baby has a high risk, then in addition to a complete examination, also given antibiotics
If infants fall into the low risk category, then there are 2 choices. The first is to do blood culture, urine, lumbar puncture, and antibiotics in the hospital. The second option is to do urine culture and observation without antibiotics unless the culture results are found to be positive. Regardless of the choice, follow-up evaluation should be done within 24-48 hours.2,3 The decision to observe at home or hospital returns to parents' ability to observe carefully, facilitate access to health services, and ensure follow- up.
Selected antibiotics are the same as the age group <28 days.3
Child 3 - 36 months
In this age group, the first one was to cluster whether the fever of the child was <390C or ≥ 390C.2,3,6
Fever <390C
What should be done is a careful history of the disease and physical examination to try to locate the cause of fever.2 Generally, no laboratory examination and antibiotics should be performed if the child appears to be well, given antipyretics. However the parent or caregiver should bring the child back if the fever continues within 2-3 days or if the condition of the child worsens.
Fever ≥ 390C
The latest recommendations for this group are: 2,3,6
Urine culture in all children <2 years of antibiotics prescribed
Chest x-ray in children with shortness of breath, rapid breathing rate, ronkhi (abnormal sound when examined by stethoscope), decreased breathing sound, or oxygen saturation (with oximeter) <95%. Also in children without these symptoms who have leukocytes> 20.000 / mm3
Stool culture if there is mucus or blood in the stool, or there are> 5 leukocytes per LPB on examination of microscopic stool
Blood cultures
There are several opinions on this subject. The first opinion is to do blood culture in all children with fever ≥ 390C. The second opinion is to do it only in children with fever ≥ 390C and leukocytes> 15.000 / mm3. The third opinion does so only in children with fever ≥ 390C and leukocytes> 18,000 / mm3. While a fairly new opinion emphasizes the number of neutrophils (one type of leukocytes, consisting of rods and segments). If neutrophils ≥ 10.000 / mm3, new blood cultures are done.
Giving antibiotics
Antibiotics are given by the same criteria as determining whether or not a blood culture is needed. Administration of antibiotics may also be considered if parents or caregivers are not reliable for follow-up evaluation.
The antibiotics selected were ceftriaxone, 50 mg / kg / day in a single dose or cefuroxime, 150-200 mg / kg / day in divided doses every 6-8 hours.
Follow-up in 24-48 hours
To see febrile treatment algorithms without any obvious cause in children <3 years, please refer to source number 2.
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