281 - Etiology, Clinical Course, and Practice Patterns in the Evaluation of Children Presenting to the Emergency Department with Prolonged Fever

Publication Number: 281.4644

Tamar R. Lubell, Columbia University Irving Medical Center, Ardsley, NY, United States; Son H. McLaren, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States; Nancy Prem, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States; Sripriya Shen, Columbia University Vagelos College of Physicians and Surgeons, Hartsdale, NY, United States; Sharon R.. Newman-Meininger, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States; Pamela Flores-Sanchez, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States; Alex Brown, columbia University, Bronx, NY, United States; Eyar Shany, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States; Peter Dayan, Columbia University, Hastings on Hudson, NY, United States

Background: A lack of data on the etiologies and expected course of seemingly prolonged fever, combined with parental and clinician uncertainty, may lead to unnecessary testing, antibiotic use, and repeat visits.

Objective: To determine the etiology, proportion with severe illness, and clinical course of children with prolonged fever, as well as emergency department (ED) clinician practice patterns.

Design/Methods: Prospective observational study of otherwise healthy children 3 months to 17 years presenting to the ED with temperature ≥38.0 C for ≥5 days. Data sources: Prospective ED clinician and caregiver case report forms and telephone follow-ups at 1 and 2 weeks post-ED visit and medical records review. Severe outcome was defined as ICU admission, shock requiring ionotropic support, or disease likely to cause morbidity or mortality within 1 month of ED visit without intervention. We used standard descriptive statistics to summarize data.

Results: Of 232 enrolled, 211 (90.9%) had telephone follow-up. Table 1 describes population characteristics. The etiology was infectious in 223 (96.1%), rheumatologic in 8 (3.4%; 5 Kawasaki disease), and unknown in one (0.4%). Infectious etiologies were viral alone in 132/223 (59.2%) and mixed viral with presumed or confirmed bacterial co-infection in 64 (28.7%), including 30 otitis media and 13 strep pharyngitis. 1/118 with blood cultures obtained had bacteremia (0.8%; associated with UTI), and 6/56 tested (10.7%) met the definition of UTI. CXRs had focal consolidation in 21/147 (14.3%); 16/21 consolidations (76.2%) were associated with a concomitant viral infection. Eight patients (3.4%) were identified with severe disease: 5 KD, all with clinical stigmata, 1 Dengue with travel history, 1 rheumatic fever with rash and knee swelling, and one female infant with an E. coli bacteremic UTI.
In 201 without severe illness and available data, 127 (63.2%) had fever resolution within 1 day and 155 (77.1%) within 2 days of ED visit, of which 90 (44.8%) were not treated with antibiotics. The median fever duration was 8 days (IQR 6, 10). No patients had a new severe diagnosis within 1-month. ED clinician practice patterns are presented in Table 2.

Conclusion(s): In children with fever ≥5 days, self-limiting viral infections predominate, with most experiencing fever resolution within 1-2 days of ED visit. Severe disease was uncommon and generally clinically identifiable. A large proportion of children underwent laboratory and/or imaging studies and received antibiotics, underscoring the need for further research to guide clinical practice to reduce unnecessary testing and antibiotic use.

Table 1. Patient demographics, clinical findings, and disposition
ED: Emergency department

Table 2. ED clinician practice patterns
ED: emergency department, PCR: polymerase chain reaction

Table 1. Patient demographics, clinical findings, and disposition
ED: Emergency department

Table 2. ED clinician practice patterns
ED: emergency department, PCR: polymerase chain reaction