Parent of a 1 year-old female on home parenteral nutrition secondary to short bowel syndrome (necrotizing enterocolitis) calls with a 2-day history of fever 101 degrees Fahrenheit (38.3 degrees Celsius). There are no other clinical complaints besides from teething.
What is the next step?
A. Prescribe acetaminophen or another over-the-counter anti-pyretic. If fever persists for another 2-3 hours, tell family to call back.
B. Check complete blood count (CBC) as outpatient. If white blood count elevated, consider further work-up.
C. Refer to the local emergency department for bacteremia work-up.
D. Offer parent reassurance and monitor clinically off antibiotics.
E. Order oral antibiotics to local pharmacy for possible viral infection.
The correct answer is c. Over 50% of patients on HPN due to intestinal failure presenting to the emergency department be diagnosed with bacteremia. Conservative management includes prompt referral to the emergency department for any fever higher than 100.4 or 38 degrees celcius. Fevers with bacteremia may or may not resolve with anti-pyretics, so the response to medications should not be used as a diagnostic sign. Blood cultures are usually positive within 24-48 hours. However, the patient’s clinical status may deteriorate in the meantime. Empiric treatment with oral antibiotics for a virus is not clinically appropriate.
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