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Continuity Clinic Notebook:

 Chapter II. The Evaluation of the Sick Child

Chapter 2 Index

A. Evaluation by system

B. Other categories of illnesses:

1. Metabolic and Endocrine

2. Collagen-Vascular Illnesses

3. Chromosomal Abnormalities

4. Generalized

  

R/O Sepsis - Case Histories

(Pediatrics 1995; 95:623-627)

3 cases:

Case 1: 3 wk old temp of 38.5 degrees; child not toxic; no source for fever identified on PE. Parents college-educated and reliable.

Choices:

1. Complete sepsis workup: blood, CSF, ua cultures; CBC, diff, ua, examine CSF for cells, protein and glucose; admit child; begin parenteral antibiotics pending culture results.

2. Evaluations as above; admit and observe

3. Perform sepsis evaluation; if UA and LP are normal, WBC <15000 with <5% bands, give IM injection of Rocephin, send child home with specific instructions; see in AM

4. Do CBC, UA blood culture, but no LP. If WBC <15000 and <5%bands, and UA is clear, give IM Rocephin, send child home, return in AM

5. Do CBC, UA, blood culture and Urine culture but no LP.  If WBC <15000 with <5% bands, and UA is clear, send child home with no antibiotics; schedule appointment for next day.

6. Do no tests, send child home with no antibiotics; see in AM

7. Other: describe

Case 2: 2 month old with rectal temp of 38.7. Good family you know well.  Child irritable, diarrhea and a URI. Child does not appear toxic and is well hydrated and easily consolable.  PE shows BOM and inspiratory crackles.  Which lab tests would you do:

1. CBC and diff  5. Blood culture
2. Urinalysis 6. Urine culture
3. Chest X-Ray 7. Stool culture
4. Stool for WBC 8. LP

Assume that any tests you obtained were normal including WBC <15000, <5% bands, nl UA etc; how would you manage this patient?

Case 3:
20-month-old with temp of 40.  Family good will return if necessary.  Child is slightly irritable, no other symptoms.  Child not toxic; PE negative. What tests would you obtain:

1. CBC and diff 5. Blood culture
2. UA 6. Urine culture
3. Chest X-Ray 7. Stool culture
4. Stool for WBC 8. LP

All tests negative, how would you manage this patient

Results Case 1: infant:

*1. Complete sepsis WU, admit, start antibiotics 37%
*2. Complete sepsis WU, admit, observe 2%
3. Complete sepsis WU neg; IM Rocephin, home  25%
4. CBC, UA, UC, BC, no LP; neg; IM Roc; home 2%
5. CBC, UA, UC, BC, if neg; home - no antibiotic 19%
6. No tests see in AM  9%
*Practice guidelines suggest.  

Results: Case 2: 2 month old with BOM and inspiratory crackles

1. CBC 56%
2. UA 13%
3. CXR 60%
4. Stool for WBCs  3%
* 5. CBC, UA, stool for WBC, CXR 1%
**6. CBC, UA, CXR 9.5%
7. CBC, CXR  45%
8. No tests 27%
9. treatment with negative tests 
- po antibiotics
- IM ceftriaxone
- no antibiotics  
82%
13%
5%
* consistent with guidelines
**possibly consistent with guidelines

Results: Case 3: 20 month old with 40 degree temp; neg exam except slightly irritable:

*1. CBC 75%
2. UA 60%
3. Blood culture  33%
4. Urine culture 14%
 5. LP 4%
*6. No antibiotics 94%
7. IM Ceftriaxone   3%
*consistent with guidelines

MCG Residents Compared to Practitioners: Percentage Compliance with Practice Guidelines
Published as letter to the editor: Benjamin JT. Pediatrics 1996;97:604-605.

Cases: MCG Residents: N=30 Utah Pediatricians N=94
Case One: 3 week old with fever 90% 39%
Case Two: 2 mo old with fever, bilateral otitis media, and rales 12% 5%
Case Three: 20 month old with fever of 40 degrees; neg. PE 82% 94%

SUM: no pediatrician followed the guidelines for all 3 cases.  No difference between practicing and academic pediatricians.  Those out less than five years more likely to follow guidelines for the 21-day-old, but not the other two cases. Doctors do fewer tests and less hospitalization than guidelines indicate they should do.

References:

1. Young PC. The Management of Febrile Infants by Primary-Care Pediatricians in Utah: Comparison with Published Practice Guidelines. Pediatrics. 1995;95:623-627

2. Baraff LJ, Bass JW, Fleisher GR, et al. Practice Guidelines for the management of infants and children 0 to 36 months of age with fever without source. Pediatrics. 1993;92:1-11

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Department of Pediatrics  |  Medical College of Georgia
 Please email comments, suggestions or questions to:
John T.  Benjamin M.D.,  jbenj@mcg.edu

February 27, 2004