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Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other!
You are seeing a 10 week old infant with a 38 degree fever of 6 hours duration. He has mild rhinorrhea as does Dad. He is otherwise well and feeding well. Point of care RSV and influenza are negative, and urine shows no pyuria or bacteriuria. Review of the chart shows mom was GBS+ and was treated with intrapartum penicillin as recommended. Baby was observed for 2 days in the nursery but not treated with antibiotics.
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December 22, 2017 at 8:25 am
this is by far the most vexing group in pediatric emergency medicine. I often (only half jokingly) say that we argued more about this in fellowship than any other group put together. in this particular history I’m not too worried about the GBS hx as the child is too old for vertically transmitted early onset GBS, and is at the same population risk for late onset GAS. I think at the very least everyone would (and should) send a urine. blood work and lp in my opinion remains controversial. this is in neonates who appear well and otherwise healthy. there have been several studies about a “sequential work up” however i think the latest jama paper which is a sub group analysis of febrile neonates and the predictive value of wbc really calls in to question the ability of us to use laboratory data to risk stratify febrile neonates. rubber meeting the road in a well appearing 10 week old with 6 hours of fever and a reliable family, I think it is very reasonable to send a urine, if negative send home with next day pediatrician follow up.
December 22, 2017 at 1:06 pm
It’s all a numbers game, right? What’s your tolerance for risk? The latest epidemiological data per uptodate is that late onset GBS occurs in 0.3 per 1000 live births, (0.73 per 1000 in African-American), but I was unable to find the rate among infants of known GBS+ moms. Maternal intrapartum antibiotic prophylaxis has no effect on late onset GBS. Late onset GBS occurs most commonly at 4-5 weeks old, but with a range of 7-89 days.
December 22, 2017 at 9:02 am
is he vaccinated?
December 22, 2017 at 12:50 pm
Yes, let’s say he is. But vaccines don’t do anything for late GBS, so that’s the conundrum