Odağı Bilinmeyen Ateş
Özet
Ateş bir hastalık olmayıp başta enfeksiyon olmak üzere enfeksiyon dışı bir çok durumda ortaya çıkan bir belirtidir. Ateş çocuklarda poliklinik ve acil servis başvurularının en sık nedenlerinden birisidir. İyi görünen hasta görünümde olmayan ve yedi günden kısa süren ve akut başlangıçlı ateşi olan çocuklarda öykü ve fizik muayene ile ateşin muhtemel sebebinin bulunamadığı durum akut odağı bilinmeyen ateş olarak tanımlanmaktadır. Çocuklarda odağı bilinmeyen ateşin en sık nedeni kendini sınırlayan viral enfeksiyonlardır. Pnömokok ve H. influenzae, tip b’ye karşı aşılama sonrası bakteriyemi riski dramatik olarak azalmış olup aşıları tam olmayan yenidoğan ve küçük bebeklerde bakteriyemi riski halen yüksektir. Hastaların yönetimi yaş, aşı durumu, yakın izleminin yapılıp yapılmamasına göre değişmektedir. Hasta ve toksik görünen bebeklerin mutlaka hastaneye yatırılması ve sepsis açısından değerlendirilmesi gerekir. Ateşli çocuk hastada ayrıntılı öykü ve detaylı muayene ile ateş odağının saptanması ve odağı bulunamayan çocuklarda invaziv bakteriyel enfeksiyon için riskli bebeklerin belirlenmesi hastaların yönetiminde son derece önemlidir. Hastaların izleminde bir çok rehber bulunmakla birlikte yaşanılan bölgenin sosyokültürel düzeyi ve imkanlarına göre her hastanın ayrıca değerlendirilmesi gerekmektedir.
Referanslar
Ward MA, Hannemann NL. Fever: Pathogenesis and treatment. In: Feiginand Cherry’s Textbook of Pediatric Infectious Diseases, 8th ed, Cherry JD, Harrison G, Kaplan SL, et al (Eds), Elsevier, Philadelphia 2018. p.52.
Mackowiak PA, Wasserman SS, Levine MM. A critical appraisal of 98.6 degrees F, the upper limit of the normal body temperature, and other legacies of Carl Reinhold August Wunderlich. JAMA.
1992;268(12):1578-1580. PMID: 1302471
Wunderlich CA, Seguin E. Medical Thermometry, and Human Temperature. 27 Great Jones Street: William Wood; 1871. 1815-1877
Geneva II, Cuzzo B, Fazili T, Javaid W. Normal Body Temperature: A Systematic Review. Open Forum Infect Dis. 2019; 9;6(4):ofz032. doi: 10.1093/ofid/ofz032
Herzog LW, Coyne LJ. What is fever? Normal temperature in infants less than 3 months old. Clin Pediatr (Phila). 1993;32(3):142-6. doi: 10.1177/000992289303200303
Wing R, Dor MR, McQuilkin PA. Fever in the pediatric patient. Emerg Med Clin North Am. 2013;31(4):1073-96. doi: 10.1016/j.emc.2013.07.006
Finkelstein JA, Christiansen CL, Platt R. Fever in pediatric primary care: occurrence, (management, and outcomes. Pediatrics. 2000; 105:260-266. PMID: 10617733
Greenes DS, Harper MB. Low risk of bacteremia in febrile children with recognizable viral syndromes. Pediatr Infect Dis J. 1999;18(3):258-61. doi: 10.1097/00006454-199903000-00010
Baraff LJ, Bass JW, Fleisher GR, et al. Practice guideline for the management of infants and children 0 to 36 months of age with fever with out source. Agency for Health Care Policy and Research. Ann Emerg Med. 1993;22(7):1198-210. doi: 10.1016/s0196-0644(05)80991
Golan N, Mor M, Yaniv N, et al. Incidence, Characteristics, and Outcomes of Clinically Undetected Bacteremia in Children Discharged Home From the Emergency Department. Pediatr Infect Dis J. 2022;41(10):819-823. doi: 10.1097/INF.0000000000003639
Greenhow TL, Hung YY, Herz A. Bacteremia in Children 3 to 36 Months Old After Introduction of Conjugated Pneumococcal Vaccines. Pediatrics. 2017; 139(4):e20162098. doi: 10.1542/peds.2016-2098
Whitney CG, Goldblatt D, O'Brien KL. Dosing schedules for pneumococcal conjugate vaccine: considerations for policy makers. Pediatr Infect Dis J. 2014; 33 Suppl 2 (Suppl 2 Optimum Dosing of Pneumococcal Conjugate Vaccine For Infants 0 A Landscape Analysis of Evidence Supportin g Different Schedules):172-81. doi: 10.1097/INF.0000000000000076
Baraff LJ, Oslund S, Prather M. Effect of antibiotic therapy and etiologic microorganism on the risk of bacterial meningitis in children with occult bacteremia. Pediatrics. 1993 Jul;92(1):140-143. PMID: 8516060
Jhaveri R, Shapiro ED. Fever Without Localizing Signs. Principles and Practice of Pediatric Infectious Diseases. 2018:115–117. doi: 10.1016/B978-0-323-40181-4.00014-1
Irwin AD, Drew RJ, Marshall P, et al. Etiology of childhood bacteremia and timely antibiotics administration in the emergency department. Pediatrics. 2015;135(4):635-42. doi: 10.1542/peds.2014-2061
Greenhow TL, Hung YY, Pantell RH. Management and Outcomes of Previously Healthy, Full-Term, Febrile Infants Ages 7 to 90 Days. Pediatrics. 2016;138(6):e20160270. doi: 10.1542/peds.2016-0270
Dagan R, Powell KR, Hall CB, Menegus MA. Identification of infants unlikely to have serious bacterial infection although hospitalized for suspected sepsis. J Pediatr. 1985;107(6):855-60. doi: 10.1016/s0022-3476(85)80175-x
Smitherman HF, Macias CG. The febril neonate (28 days of age or younger): Out patient evaluation and initial management. In: Teach SJ, Kaplan SL, Edwards MS editor UpToDate. Waltham:upToDate, (updated: Feb 21, 2023; literature review: Nov 2023) https://www.uptodate.com/contents/the-febrile-neonate-28-days-of-age-or-younger-outpatient-evaluation-and-initial-management. Acsessed 20. Dec 2023.
Centers for Disease Control and Prevention (CDC). Trends in perinatal group B streptococcal disease–United States, 2000-2006. MMWR Morb Mortal WklyRep2009;58:109–112.
Garcia S, Mintegi S, Gomez B, et al. Is 15 days an appropriate cut-off age for considering serious bacterial infection in the management of febrile infants? Pediatr Infect Dis J. 2012; 31(5):455-8. doi: 10.1097/INF.0b013e318247b9f2.
Pantell RH, Roberts KB, Adams WG, et al. Evaluation and Management of Well-Appearing Febrile Infants 8 to 60 Days Old. Pediatrics. 2021;148(2): e2021052228. doi: 10.1542/peds.2021-052228.
Demmler-Harrison G. Neonatal Herpes simplex virus infection: Clinical features and diagnosis. In: Kaplan SL, editor UpToDate.Waltham: upToDate; (updated: Nov 14, 2022; literaturereview: Nov 2023).https://www.uptodate.com/contents/neonatal-herpes-simplex-virus-infection-clinical-features-and-diagnosis. Acsessed 20. Dec 2023.
Kuppermann N, Mahajan P, Dayan PS. Fever, Absolute Neutrophil Count, Procalcitonin, and the AAP Febrile Infant Guidelines. Pediatrics. 2023; 151(2):e2022059862. doi: 10.1542/peds.2022-059862
Hui C, Neto G, Tsertsvadze A, et al. Diagnosis and Management of Febrile Infants (0-3 months). Evidence Report/Technology Assessment No. 205 (Prepared by the University of Ottawa: Evidence-based Practice Center under Contract No. HHSA 290-2007-10059-I). AHRQ Publication No. 12-E004-EF. Rockville, MD: Agencyfor Healthcare Researchand Quality. March 2012. Available at http://www.ahrq.gov/research/findings/evidence-based-reports/febrinftp.html (AccessedAugust 3, 2015)
Smitherman HF, Macias CG. The febril infant (29 to 90days of age): Out patient evaluation. In: Teach SJ, Kaplan SL, editor. UpToDate. Waltham: upToDate , (updated: Feb 21, 2023; literature review: Nov 2023). https://www.uptodate.com/contents/the-febrile-infant-29-to-90-days-of-age-outpatient-evaluation. Acsessed 20. Dec 2023.
Cruz AT, Mahajan P, Bonsu BK, et al. Accuracy of Complete Blood Cell Counts to Identify Febrile Infants 60 Days or Younger With Invasive Bacterial Infections. JAMA Pediatr. 2017 6;171(11):e172927. doi: 10.1001/jamapediatrics.2017.2927
Bonilla L, Gomez B, Pintos C, Benito J, Mintegi S. Prevalence of Bacterial Infection in Febrile Infant 61-90 Days Old Compared WithYounger Infants. Pediatr Infect Dis J. 2019; 38(12):1163-1167. doi: 10.1097/INF.0000000000002461
Gómez B, Mintegi S, Benito J, Egireun A, Garcia D, Astobiza E. Blood culture and bacteremia predictors in infants less than three months of age with fever without source. Pediatr Infect Dis J. 2010 Jan;29(1):43-7. doi: 10.1097/INF.0b013e3181c6dd14
Gomez B, Mintegi S, BressanS, Da Dalt L, Gervaix A, Lacroix L; European Group forValidation of the Step-by-Step Approach. Validation of the "Step-by-Step" Approach in the Management of Young Febrile Infants. Pediatrics. 2016;138(2):e20154381. doi: 10.1542/peds.2015-4381
Palazzi DL. Fever without source and fever of unknown origin. In: Cherry JD, Harrison GJ, Kaplan SL, Steinbach WJ, et al. (eds). Feigin and Cherry’s Textbook of Pediatric Infectious Diseases, 8 th Ed. Philedelphia: Elsevier Inc;2019:17-30.
Shaw KN, Gorelick M, McGowan KL, Yakscoe NM, Schwartz JS. Prevalence of urinary tract infection in febrile young children in the emergency department. Pediatrics. 1998; 102(2):e16. doi: 10.1542/peds.102.2.e16
Hoberman A, Chao HP, Keller DM, Hickey R, Davis HW, Ellis D. Prevalence of urinary tract infection in febrile infants. J Pediatr. 1993; 123(1):17-23. doi: 10.1016/s0022-3476(05)81531-8
Bachur R, Perry H, Harper MB. Occult pneumonias: empiric chest radiographs in febrile children with leukocytosis. Ann Emerg Med. 1999; 33(2):166-73. doi: 10.1016/s0196-0644(99)70390-2
Allen CH. Fever without a source in children 3-36 months of age: Evaluation and management. In: Kaplan SL, Neuman MI, editor. UpToDate. Waltham: upToDate, (updated: Nov 14, 2023; literaturereview: Nov 2023). https://www.uptodate.com/contents/fever-without-a-source-in-children-3-to-36-months-of-age-evaluation-and-management. Acsessed 20. Dec 2023.
For Academic College of Emergency Experts in India (ACEE-INDIA) – INDO US Emergency and Trauma Collaborative; Mahajan P, Batra P, Thakur N, Patel R, Rai N, Trivedi N, Fassl B, Shah B, Lozon M, Oteng RA, Saha A, Shah D, Galwankar S. Consensus Guidelines on Evaluation and Management of the Febrile Child Presenting to the Emergency Department in India. Indian Pediatr. 2017; 54(8):652-660. doi: 10.1007/s13312-017-1129-8
Paul SP, Kini PK, Tibrewal SR, Heaton PA. NICE guideline review: fever in under 5s: assessment and initial management (NG143). Arch Dis Child Educ Pract Ed. 2022 Jun;107(3):212-216. doi: 10.1136/archdischild-2021-321718.
