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MORNING REPORT

10/24/18
WADE HARRISON, MD, MPH

©UNIVERSITY OF UTAH HEALTH, 2017


PATIENT 1: INITIAL PRESENTATION
PCH ED:
• HPI: 63do with 2 days of fussiness, eye discharge, and
rhinorrhea, 1 day of emesis and decreased PO, and temp to
102o at home. Older sisters and Dad with recent URI.
• PMHx: 38w0d. Imperforate anus w/ persistent cloaca s/p
colostomy at DOL#3. ASD/VSD and rib anomalies.
• PE: 38.5o requiring 0.25L NC / well-appearing / no eye
discharge or rhinorrhea/ Nml WOB and clear lungs
• Initial Labs:
CBC: WBC 10.3 (B 34%, N 21%, L 38%), Hgb 8.0, Plts 486
VRP: rhino+
Urine: unsuccessful catheterization attempt
CXR: mild peribronchial thickening and perihilar patchiness

©UNIVERSITY OF UTAH HEALTH, 2017


HOSPITAL COURSE
HD1: Weaned to 0.06L NC but continues to fever. Well appearing
on exam.
• Bag UA: failed x2
• Cath UA by Urology: small LE, no nitrites, WBC 12/HPF, 1+ Bact

©UNIVERSITY OF UTAH HEALTH, 2017


PATIENT 2: INITIAL PRESENTATION
Day 1: Urgent Care
• HPI: 47do with several days of nasal congestion/eye discharge,
cough x1day, fever to 100.4 (temporal) this morning. Feeding
well, normal UOP. Whole family sick – 2yo brother is being seen
at same time for cough and sore throat.
• PMHx: 36w2d. Uncomplicated pregnancy/birth hospitalization
• PE: Afebrile w/ nml vitals / well-appearing / +eye discharge but
clear conjunctiva / +nasal congestion / Nml WOB and clear
lungs
• Dispo: Viral URI and sent home with return precautions

©UNIVERSITY OF UTAH HEALTH, 2017


URGENT CARE BOUNCE BACK
Day 1: Urgent Care: viral URI

Day 2: Urgent Care


• HPI: No additional fevers but cough/congestion not improved
• PE: Vitals nml / “Tired but nontoxic” / otherwise nml
• Labs:
UA: >1.029, Tr Hgb, 1+ Pro, Neg LE/Nit/Glu | UCx: pending
• Dispo: Sent home
_________________________________________________________________________________________________________________________________________________

CBC: WBC 11.1 (B 2%, N 37%, L 52%), Hgb 12.8, Plts 356
VRP: rhino+

• Dispo: Called family and told labs reassuring still likely viral URI
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SERIOUSLY – WHY IS THIS KID STILL SICK
Day 1: Urgent Care: viral URI
Day 2: Urgent Care: UA and CBC reassuring -> rhinovirus URI

Day 3: PCH ED
• HPI: Return of fever, not feeding well, decreased activity, less
UOP, continued eye discharge
• PE: 38.0o otherwise nml / well appearing / sunken fontanelle /
+purulent eye discharge
• Labs:
CBC: WBC 15.2 (B 19%, N 2%, L 57%), Hgb 12.1, Plts 546
RSV: negative
Urine: unsuccessful catheterization attempt
• Dispo: 10cc/kg bolus and d/c home

©UNIVERSITY OF UTAH HEALTH, 2017


SUBSEQUENT FOLLOW-UP
Day 1: Urgent Care: viral URI
Day 2: Urgent Care: UA and CBC reassuring -> rhinovirus URI
Day 3: PCH ED: CBC, unsuccessful urine, bolus, and d/c home

Day 4 midday: PCP


• Told to f/u from ED visit. Congested but otherwise well.
• Noted that UCx from 9/23 grew 50,000 CFU Citrobacter koseri
• Dispo: Sent to PCH ED for LP
Day 5 evening: PCH ED
• PE: Afebrile / fussy but consolable / nasal congestion
• Labs:
CSF: WBC 98 (promyelocyte 1%, myelo 2%, metamyelo 12%, bands 33%,
N 1%, L 45%, M 5%, E 1%), RBC 2k, Pro 70, Glu 43
Men/Enc PCR: negative
Urine: bladder tapping unsuccessful
• Dispo: Admitted and started on Amp, Gent, CTX, Acyclovir
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©UNIVERSITY OF UTAH HEALTH, 2017


HOSPITAL COURSE
Day 1: Urgent Care: viral URI
Day 2: Urgent Care: UA and CBC reassuring -> rhinovirus URI
Day 3: PCH ED: CBC, unsuccessful urine, bolus, and d/c home
Day 4: PCH ED: Admitted and empiric treatment for bacterial meningitis and HSV

Day 5: HD1: Afebrile. Snotty as stink but on room air.


• UA (bag): No LE/Nit
• Abx: d/c Amp/Gent/CTX and Acyclovir. Start Cefepime.
• Path: CSF consistent with bone marrow contamination
Day 6: HD2: Remains afebrile and snotty.
• Labs:
CBC: WBC 10.1 (myelo 14%, meta 1%, B 7%, N 21%), Hgb 12.9, Plts 396
CRP: 1.3
• Imaging:
MRI Brain: Normal. No signs of meningitis or abscess.
RBUS: Normal.
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©UNIVERSITY OF UTAH HEALTH, 2017


FEBRILE INFANTS – WHY DO WE CARE?
• Risk of SBI: 9.7% (PECARN: Mahajan 2018)
– UTI: 8.4%
– Bacteremia: 1.8%
– Meningitis: 0.5%
– <28 days1: 12.5% vs. 7%
• Viral Coinfection
– Any Virus: 3.7% vs. 12.7% (Mahajan 2018)
• UTI: 2.8% vs. 10.7%
• Bacteremia: 0.8% vs. 2.9%
• Meningitis: 0.4% vs. 0.8%
– RSV: UTI: 5.1% | Bacteremia: rare | Meningitis: none (Ralston 2011)
– Rhino: UTI: 6.2% | Bacteremia: 1.5% | Meningitis: 0.1% (Blaschke
2018)
• Rhino may reduce risk of UTI and Bacteremia in 29-90 day olds
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©UNIVERSITY OF UTAH HEALTH, 2017


PRACTICE VARIATION: DATA
• KPNC: 1380 infants 7-90 days old presenting for fever
– 7-28d
• Full Work-up: 59%
• Blood and Urine: 12%
• Urine only:
• No culture: 24%
– 29-60d
• Full Work-up: 25%
• Blood and Urine: 35%
• Urine only: 4%
• No culture: 28%
– 61-90d
• Full Work-up: 5%
• Blood and Urine: 32%
• Urine only: 8%
• No culture: 44% 10

©UNIVERSITY OF UTAH HEALTH, 2017


PRACTICE VARIATION: PATHWAYS
PCH CHOP Seattle REVISE
Population 7-60 days
0-90 days 0-56 days 0-60 days

High Risk 0-28 days 0-28 days 0-28 days <37 weeks GA
(i.e. Do I need <37 weeks GA <37 weeks GA <37 weeks GA Underlying condition _____________________________________________________________________________________________________________________________________

Underlying condition Underlying condition Underlying condition WBC <5k or >15


an LP?) _____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________

WBC <5k or >15 Prolonged


_____________________________________________________________________________________________________________________________________
WBC <5k or >15 Bands >1500
Bands >1500 WBC <5k or >15 Bands >1500 UA: LE, Nit, >5
UA: LE, Nit, Bact, Bands/Neuts >0.2 UA: LE, Nit, Bact, WBC/HPF
>10 WBC/HPF
_____________________________________________________________________________________________________________________________________
UA: Bact, >10 >10 WBC/HPF
+ RSV (others?) WBC/HPF
Viral Testing If admission planned With symptoms With symptoms With symptoms
HSV <42d and ill, seizures, <21d 0-30d and ill, AMS/ Seizures, vesicular
vesicular rash, <or> seizures, HSM, rash, rash, maternal HSV,
abnormal CSF 21-40d w/: ill, AMS/ known exposure, CSF pleocytosis
seizures, hepatitis, conjunctivitis,
vesicular rash, known pneumonitis,
maternal HSV thrombocytopenia, or
pleocytosis w/o bact.
Inflammatory CRP and/or
Markers Procalcitonin
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©UNIVERSITY OF UTAH HEALTH, 2017


STEP-BY-STEP APPROACH

• Predicts IBI not SBI

• High Risk: 8.1%


– Full work-up

• Intermediate Risk: 3.4%


– May need full work-up

• Low Risk: 0.7%

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©UNIVERSITY OF UTAH HEALTH, 2017


REFERENCES

1. Mahajan P, Browne LR, Levine DA, et al. Risk of Bacterial Coinfections in Febrile
Infants 60 Days Old and Younger with Documented Viral Infections. J Pediatr.
September 2018. doi:10.1016/j.jpeds.2018.07.073
2. Ralston R, Hill V, Waters A. Occult Serious Bacterial Infection in Infants Younger
Than 60 to 90 Days With Bronchiolitis: A Systematic Review. Arch Pediatr
Adolesc Med. 2011;165(10):951-956. doi:10.1001/archpediatrics.2011.155
3. Blaschke AJ, Korgenski EK, Wilkes J, et al. Rhinovirus in Febrile Infants and Risk of
Bacterial Infection. Pediatrics. 2018;141(2)
4. Greenhow TL, Hung Y-Y, Pantell RH. Management and Outcomes of Previously
Healthy, Full-Term, Febrile Infants Ages 7 to 90 Days. PEDIATRICS. 2016;138(6)

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©UNIVERSITY OF UTAH HEALTH, 2017