UBC Objectives: Maternity Care, Priority Topic: Fever, Priority Topic: Newborn, & Priority Topic: Urinary Tract Infection

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...​

• Initiate management of common neonatal problems including those conditions requiring urgent intervention or referral

Fever

Key Feature 1a: In febrile infants 0-3 months old: Recognize the risk of occult bacteremia. 
Skill: Clinical Reasoning
Phase: Hypothesis generation, Diagnosis

Key Feature 1a: In febrile infants 0-3 months old: Investigate thoroughly (ex: blood cultures, urine, lumbar puncture +/- chest X-ray). 
Skill: Clinical Reasoning
Phase: Investigation

Key Feature 8: In an elderly patient, be aware that no good correlation exists between the presence or absence of fever and the presence or absence of serious pathology. 
Skill: Clinical Reasoning
Phase: Hypothesis generation

Newborn

Key Feature 2a: In a newborn, where a concern has been raised by a caregiver (parent, nurse): Think about sepsis.
Skill: Clinical Reasoning
Phase: Hypothesis generation

Key Feature 2b: In a newborn, where a concern has been raised by a caregiver (parent, nurse): Look for signs of sepsis, as the presentation can be subtle (i.e., not the same as in adults, non-specific, feeding difficulties, respiratory changes).
Skill: Clinical Reasoning, Selectivity
Phase: Physical, History

Key Feature 2c: In a newborn, where a concern has been raised by a caregiver (parent, nurse): Make a provisional diagnosis of sepsis.
​Skill: Clinical Reasoning
Phase: Diagnosis

Urinary Tract Infection

Key Feature 5: Given a non-specific history (ex: abdominal pain, fever, delirium) in elderly or very young patients, suspect the diagnosis and do an appropriate work-up.
Skill: Clinical Reasoning
Phase: Hypothesis generation, Investigation

When I was in my third year of medical school I encountered a febrile infant in clinic who was just over a month old. My attending family physician recommended the parents bring their infant immediately to the Emergency Department, and because I was on a rural rotation, I had the privilege of heading over to the Emergency Department myself to follow the workup through. 

My preceptor urgently referred this infant to the Emergency Department because of the heightened risk of occult bacteremia in febrile infants under 3 months of age. According to the UpToDate article, Febrile infant (younger than 90 days of age): Definition of fever (2018), "Neonates and young infants may manifest fever as the only sign of significant underlying infection. The incidence of serious bacterial infection such as urinary tract infection, bacteremia, meningitis, and pneumonia is higher in infants younger than three months of age, particularly those under 28 days, than at any other time in childhood. In addition, these young patients can experience significant morbidity from some viral infections." A fever in a child less than 3 months old warrants an urgent workup in an Emergency Department as this can be the first sign of a potentially life-threatening infection/sepsis. The Emergency Department is the place in our healthcare system where this workup can be completed the most urgently and with the resources to do so as extensively as indicated.

So what exactly does the workup of a febrile infant less than 3 months of age entail? Per the UpToDate article, Approach to the ill-appearing infant (younger than 90 days of age) (2018), and the BC Children's Hospital Febrile Infant Guideline, the investigations that are indicated in this situation include: 

1. STAT blood culture (x2) 
2. STAT bedside glucose
3. STAT CBC with differential
4. STAT electrolytes, creatinine, urea, glucose
5. STAT C-reactive protein
6. STAT bladder catheterisation for urine dip and urinalysis, microscopy, and culture & sensitivity
7. +/- CSF for gram stain, culture & sensitivity, HSV PCR, cell count with differential, and chemistry
8. +/- CXR
9. +/- Nasopharyngeal wash for rapid respiratory panel
10. +/- Stool for white blood cells and culture & sensitivity
11. +/- Others (ex: culture & sensitivity from potential foci of infection, other imaging, joint aspiration, biopsy)

I also just want to make a little pitch here about fever in the other extreme of age. Like infants, elderly patients may be impaired in their ability to mount a significant immune response to an invasive infection, and may not even develop a temperature high enough to be considered febrile (typically around 38 degrees Celsius). It is important - when encountering a newborn or elderly patient who is unwell - to have a high index of suspicion for a source of infection, even if they aren't presenting with a fever.

While the infant I encountered on this occasion had mounted a fever, other signs of sepsis to watch out for are included in the below table from UpToDate:

Furthermore, per UpToDate, "A clinical diagnosis of severe sepsis or septic shock is made in children who have signs of inadequate tissue perfusion, two or more criteria for the systemic inflammatory response syndrome (SIRS), and suspected or proven infection." See below for a table provided by UpToDate of the pediatric SIRS criteria: