You are just getting over your third viral illness this winter. Your tummy will never forget this one, but on the bright side you lost 5 pounds nibbling on saltine crackers for a week. You drink some coffee and coconut water in a hurry and arrive energized to your shift in the Pediatric ED. You walk past four kindergarteners banging popsicle sticks on the wall like they’re ready for some football.
You enter a patient’s room to encounter a three-day-old girl brought by her parents for a measured fever lasting 6 hours. Her birth history is uneventful. Her family has also noticed increased mucus production from the nose while feeding.
On exam, she is lethargic, toxic appearing, and you see mottling of her arms and legs. She is also very warm, but breath sounds are clear and there are no rashes on her skin.
Vitals-
T 103.2 F
BP-72/50 mm Hg
HR-168 / min
RR-44 breath / min
How do you screen for sepsis in children? As defined by the International Pediatric Sepsis Consensus conference (IPSCC), neonatal sepsis is defined by the presence of greater than 2 SIRS Criteria, and there must also be either leukocytosis or temperature abnormality to meet criteria. The two other additional SIRS criteria items are tachycardia or tachypnea.
You know this child needs your attention right away.
What organisms should be covered when choosing antibiotics? A child less than 29 days with a fever is considered a febrile neonate. They are high risk of pneumonia, UTI, bacteremia, and meningitis. Pathogens for these most common in neonates are E coli, Group B Strep, Listeria, and Neisseria gonorrheae.
Which neonates have increased risk for neonatal sepsis? Those children with low birth weight, prematurity, premature or prolonged membrane rupture on delivery, maternal group B strep, and meconium aspiration are at increased risk.
What treatment should be initiated? Initial management is a 20 mL/kg fluid bolus, and broad spectrum antibiotics should be initiated. Ampicillin and Cefotaxime provide good coverage for Listeria but also group B strep and E coli, respectively. Maternal herpes infection should prompt initiation of acyclovir as well. Febrile neonates should be admitted to the hospital for IV antibiotics pending cultures and improvement of symptoms.
What workup is needed to help identify a source? CBC, blood culture, UA, and urine culture should be sent. Lumbar puncture should be performed to obtain CSF for cell count, gram stain, and culture. For children with respiratory symptoms, chest X-ray should be obtained.
- Goldstein B, Giroir B, Randolph A (2005) International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med 6:2–8
- Mick NW: Pediatric fever, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. Philadelphia, Elsevier Saunders, 2014, Ch. 167:2096-2105.
- Wang VJ: Fever and serious bacterial illness, in Tintinalli JE, Stapczynski J, Ma O, Cline DM, Cydulka RK, Meckler GD, et al (eds): Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, ed 7. New York, McGraw-Hill, 2011, Ch. 113:750-755.
*Disclaimer: This post is for Board Review and is not necessarily based on up-to-date evidence.
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