Wysoka temperatura (gorączka) u dzieci – Rokowania, prognozy i postęp choroby

Wysoka temperatura (gorączka) u dzieci
Rokowania, prognozy i postęp choroby

Gorączka u dzieci jest częstym objawem o szerokim spektrum etiologicznym, od łagodnych infekcji wirusowych po ciężkie infekcje bakteryjne zagrażające życiu. Gorączka utrzymująca się ≥5 dni stanowi istotny sygnał ostrzegawczy, wiążąc się z wyższym ryzykiem poważnych infekcji bakteryjnych (SBI) oraz chorób zapalnych, takich jak choroba Kawasakiego. W badaniu obejmującym 35705 dzieci z gorączką, 10,6% miało gorączkę trwającą ≥5 dni, a ryzyko SBI wynosiło 8,4% w porównaniu do 5,7% u dzieci z krótszym czasem trwania gorączki. Predyktory przedłużonej gorączki (≥3 dni) obejmują ból gardła (OR 2,8; 95% CI 1,30–6,01) i powiększone węzły chłonne (OR 1,87; 95% CI 1,01–3,49), jednak ogólna wartość predykcyjna modelu jest niska (AUC 0,64), a pomiar CRP nie zwiększa trafności prognozy. Ryzyko inwazyjnego zakażenia bakteryjnego (IBI) jest zależne od wieku: u niemowląt <3 miesiąca wynosi 6-10%, głównie zakażenia układu moczowego, natomiast u dzieci 3 miesiące–3 lata z temperaturą rektalną ≥38,5°C ryzyko bakteriemii utajonej spadło do 0,25–0,7%.

Wysoka temperatura (gorączka) u dzieci – Rokowanie (przewidywanie wyniku)

Czynniki ryzyka przedłużającej się gorączki
Predyktory przedłużającej się gorączki
Ryzyko poważnych zakażeń w zależności od wieku
Modele predykcyjne dla gorączki neutropenicznej
Postępowanie kliniczne i rokowanie
Kolejne rozdziały

Wysoka temperatura (gorączka) u dzieci – Rokowanie (przewidywanie wyniku)

Wysoka temperatura (gorączka) jest częstym objawem u dzieci, który może być związany z różnymi chorobami – od łagodnych, samoograniczających się infekcji wirusowych, po ciężkie, zagrażające życiu infekcje bakteryjne. Rokowanie zależy przede wszystkim od przyczyny i ciężkości infekcji.¹

Czynniki ryzyka przedłużającej się gorączki

Gorączka utrzymująca się przez 5 dni lub dłużej jest uważana za sygnał ostrzegawczy potencjalnie poważnej infekcji w wytycznych dotyczących postępowania z gorączką u dzieci. Przedłużająca się gorączka wiąże się z większym ryzykiem poważnych infekcji bakteryjnych (SBI) oraz stanów nieinfekcyjnych i zapalnych, takich jak choroba Kawasakiego.²

W wieloośrodkowym prospektywnym badaniu obserwacyjnym wykazano, że 10,6% z 35705 dzieci z gorączką miało gorączkę trwającą 5 dni lub dłużej, z wyższym ryzykiem poważnych infekcji bakteryjnych (8,4% vs 5,7%). Dzieci z przedłużającą się gorączką mają wyższe ryzyko SBI, co uzasadnia dokładną ocenę kliniczną i rozważną diagnostykę, również ze zwróceniem uwagi na rzadkie, ale istotne przyczyny nieinfekcyjne.³

Predyktory przedłużającej się gorączki

Badania przeprowadzone w podstawowej opiece zdrowotnej wykazały, że gorączka u dzieci jest najczęściej spowodowana łagodnymi infekcjami, jednak często niepokoi rodziców. Informacje o przewidywanym czasie trwania gorączki i jej predyktorach mogą pomóc w uspokojeniu rodziców, prowadząc do zmniejszenia liczby konsultacji medycznych.⁴

W analizie wieloczynnikowej łączącej model historii pacjenta i badania fizykalnego wykazano, że ból gardła (OR 2,8; 95% CI = 1,30 do 6,01) i wyczuwalne węzły chłonne (OR 1,87; 95% CI = 1,01 do 3,49) są czynnikami predykcyjnymi przedłużonego czasu trwania gorączki (≥3 dni).⁵

Chociaż wyodrębniono kilka objawów i symptomów związanych z przedłużającym się czasem trwania gorączki, ogólna wartość predykcyjna modelu była niska (AUC 0,64). Oznacza to, że nie jest możliwe dokonanie trafnego przewidywania, czy u danego dziecka będzie występować przedłużająca się gorączka.⁶⁷

Dodatkowo wykazano, że pomiar białka C-reaktywnego (CRP) nie ma dodatkowej wartości predykcyjnej dla przedłużonego czasu trwania gorączki.⁸

Ryzyko poważnych zakażeń w zależności od wieku

Ryzyko inwazyjnego zakażenia bakteryjnego (IBI), takiego jak bakteriemia i bakteryjne zapalenie opon mózgowo-rdzeniowych, jest zależne od wieku.⁹

Niemowlęta poniżej 3 miesiąca życia – częstość występowania poważnych infekcji bakteryjnych wynosi około 6-10%, najczęściej są to zakażenia układu moczowego (UTI).¹⁰
Dzieci w wieku 3 miesięcy do 3 lat z temperaturą rektalną 38,5°C (101,3°F) lub wyższą – historycznie ryzyko bakteriemii utajonej wynosiło 2-4%. Obecnie częstość występowania bakteriemii utajonej w tej populacji waha się od 0,25% do 0,7%.¹¹

Modele predykcyjne dla gorączki neutropenicznej

Gorączka w neutropenii (FN) pozostaje poważnym powikłaniem terapii nowotworów u dzieci. Opracowano kliniczne reguły decyzyjne (CDR), które pomagają rozróżnić dzieci o wysokim i niskim ryzyku ciężkiej infekcji.¹²

Opracowane modele predykcyjne dla bakteriemii i zdarzeń wymagających interwencji (SRE) uwzględniają cztery charakterystyki:

Typ nowotworu
Znacznie obniżony stan ogólny
Liczba leukocytów ≤0,3 G/L
Zajęcie szpiku kostnego

¹³

Model predykcyjny dla poważnych powikłań medycznych (SMC) uwzględnia dwie cechy:

Znacznie obniżony stan ogólny
Liczba płytek krwi ≤50 G/L

¹⁴

Wydajność wszystkich trzech modeli, oceniana w walidacji krzyżowej, wykazała porównywalne lub lepsze wartości predykcyjne niż wcześniej opublikowane modele. Walidacja zewnętrzna 8 opublikowanych modeli wykazała, że 5 z nich pokazuje powtarzalne wyniki dla czułości lub swoistości.¹⁵

Postępowanie kliniczne i rokowanie

Podejście do gorączkującego dziecka w wieku od 3 miesięcy do 3 lat powinno obejmować ukierunkowany wywiad medyczny, pełne badanie fizykalne i rozważne wykorzystanie badań laboratoryjnych.¹⁶

U dzieci z przedłużającą się gorączką, ze względu na wyższe ryzyko poważnych infekcji bakteryjnych, uzasadnione jest dokładne badanie kliniczne i rozważna diagnostyka. Chociaż rzadko, klinicyści powinni również rozważyć możliwość istotnych nieinfekcyjnych przyczyn przedłużającej się gorączki.¹⁷

Warto zauważyć, że dla dzieci, które nie są bezpośrednio kierowane do opieki specjalistycznej, mediana czasu trwania gorączki po konsultacji z lekarzem podstawowej opieki zdrowotnej wynosi 1 dzień.¹⁸

Chociaż dłuższy czas trwania gorączki nie ma jednoznacznie ustalonej wartości predykcyjnej dla poważnych infekcji, może prowadzić do niepokoju rodziców, a w konsekwencji do zwiększonego wykorzystania opieki medycznej.¹⁹

Kolejne rozdziały

Zapraszamy do dalszego czytania naszego leksykonu.

Wybierz kolejny rozdział z menu poniżej, aby otworzyć nową podstronę kompedium wiedzy i uzyskać szczegółowe informację o leku, substancji lub chorobie.

Materiały źródłowe

#1 Fever in the Infant and Toddler: Practice Essentials, Background, Neonates
https://emedicine.medscape.com/article/1834870-overview
Fever may indicate a mild, self-limiting viral infection or a severe, life-threatening bacterial infection. The prognosis depends upon the cause and severity of the infection. […] The risk of invasive bacterial infection (IBI) such as bacteremia and bacterial meningitis is age dependent. […] The prevalence of a serious bacterial infection in infants younger than 3 months is approximately 6-10%, most often urinary tract infections (UTIs). […] Historically, children aged 3 months to 3 years with rectal temperatures of 38.5C (101.3F) or higher had a risk of 2-4% for occult bacteremia. […] The incidence of occult bacteremia in this population now ranges from 0.25% to 0.7%. […] The approach to the febrile child aged 3 months to 3 years consists of a targeted medical history, a complete physical examination, and the judicious use of the laboratory tests.
#2 Are children with prolonged fever at a higher risk for serious illness? A prospective observational study | Archives of Disease in Childhood
https://adc.bmj.com/content/108/8/632
A prolonged fever of five days or more is considered a warning sign for serious infection in childhood fever management guidelines. […] Prolonged fever is believed to be associated with serious bacterial infections (SBI) and with non-infectious and inflammatory conditions such as Kawasaki disease. […] In this multicentre prospective observational study, 10.6% of 35705 febrile children had a fever 5 days, with higher risk of SBI (8.4% vs 5.7%). […] Children with prolonged fever have a higher risk of SBI, warranting a careful clinical assessment and considerate diagnostic work, also with attention for rare but important non-infectious causes. […] In children with prolonged fever, there is a higher risk of SBI, warranting a careful clinical assessment and considerate diagnostic workup. […] Although rare, clinicians should consider the possibility of important non-infectious causes of prolonged fever.
#3 Are children with prolonged fever at a higher risk for serious illness? A prospective observational study | Archives of Disease in Childhood
https://adc.bmj.com/content/108/8/632
A prolonged fever of five days or more is considered a warning sign for serious infection in childhood fever management guidelines. […] Prolonged fever is believed to be associated with serious bacterial infections (SBI) and with non-infectious and inflammatory conditions such as Kawasaki disease. […] In this multicentre prospective observational study, 10.6% of 35705 febrile children had a fever 5 days, with higher risk of SBI (8.4% vs 5.7%). […] Children with prolonged fever have a higher risk of SBI, warranting a careful clinical assessment and considerate diagnostic work, also with attention for rare but important non-infectious causes. […] In children with prolonged fever, there is a higher risk of SBI, warranting a careful clinical assessment and considerate diagnostic workup. […] Although rare, clinicians should consider the possibility of important non-infectious causes of prolonged fever.
#4 Predicting prolonged duration of fever in children: a cohort study in primary care
https://pmc.ncbi.nlm.nih.gov/articles/PMC4540397/
Fever in children in primary care is commonly caused by benign infections, but often worries parents. Information about the duration of fever and its predictors may help in reassuring parents, leading to diminished consultation of health care. […] To determine which signs and symptoms predict a prolonged duration of fever in febrile children in primary care and evaluate whether C-reactive protein (CRP) measurement has an additive predictive value for these symptoms. […] The main outcome measure was prolonged duration of fever (3 days) after initial contact. […] Multivariate analysis combined model of patient history and physical examination showed that sore throat (OR 2.8; 95% CI = 1.30 to 6.01) and lymph nodes palpable (OR 1.87; 95% CI = 1.01 to 3.49) are predictive for prolonged duration of fever.
#5 Predicting prolonged duration of fever in children: a cohort study in primary care
https://pmc.ncbi.nlm.nih.gov/articles/PMC4540397/
Fever in children in primary care is commonly caused by benign infections, but often worries parents. Information about the duration of fever and its predictors may help in reassuring parents, leading to diminished consultation of health care. […] To determine which signs and symptoms predict a prolonged duration of fever in febrile children in primary care and evaluate whether C-reactive protein (CRP) measurement has an additive predictive value for these symptoms. […] The main outcome measure was prolonged duration of fever (3 days) after initial contact. […] Multivariate analysis combined model of patient history and physical examination showed that sore throat (OR 2.8; 95% CI = 1.30 to 6.01) and lymph nodes palpable (OR 1.87; 95% CI = 1.01 to 3.49) are predictive for prolonged duration of fever.
#6 Predicting prolonged duration of fever in children: a cohort study in primary care
https://pmc.ncbi.nlm.nih.gov/articles/PMC4540397/
The derived prediction model indicates that only a few signs and symptoms are related to prolonged duration of fever. CRP has no additional value in this model. Overall, because the discriminative value of the model was low, the duration of fever cannot be accurately predicted. […] Although a longer duration of fever has no clear established predictive value for serious infections, it may lead to parental concern and, subsequently, increased medical care consumption. […] This study found several signs and symptoms to be related to a prolonged duration of fever. The overall predictive value was low, however, so the duration of fever cannot be predicted for an individual patient. […] The present study shows that, for children not directly referred to secondary care, the median duration of fever after consultation with the GPC is 1 day. The multivariate analysis showed that sore throat and palpable lymph nodes were predictive for a duration of fever 3 days. The predictive value of the model was considered low (AUC 0.64). CRP had no additive predictive value for prolonged duration of fever.
#7 Predicting prolonged duration of fever in children: a cohort study in primary care
https://pmc.ncbi.nlm.nih.gov/articles/PMC4540397/
The derived model had a low predictive value for prolonged duration of fever. The median AUC was only 0.64 (SD 0.02), indicating that the performance of the model is suboptimal. Therefore, with this model it is not possible to make a valid prediction as to whether children will or will not have prolonged duration of fever. […] In conclusion, although a few signs and symptoms are predictive for a prolonged duration of fever, the discriminative value of the model is low.
#8 Predicting prolonged duration of fever in children: a cohort study in primary care
https://pmc.ncbi.nlm.nih.gov/articles/PMC4540397/
The derived prediction model indicates that only a few signs and symptoms are related to prolonged duration of fever. CRP has no additional value in this model. Overall, because the discriminative value of the model was low, the duration of fever cannot be accurately predicted. […] Although a longer duration of fever has no clear established predictive value for serious infections, it may lead to parental concern and, subsequently, increased medical care consumption. […] This study found several signs and symptoms to be related to a prolonged duration of fever. The overall predictive value was low, however, so the duration of fever cannot be predicted for an individual patient. […] The present study shows that, for children not directly referred to secondary care, the median duration of fever after consultation with the GPC is 1 day. The multivariate analysis showed that sore throat and palpable lymph nodes were predictive for a duration of fever 3 days. The predictive value of the model was considered low (AUC 0.64). CRP had no additive predictive value for prolonged duration of fever.
#9 Fever in the Infant and Toddler: Practice Essentials, Background, Neonates
https://emedicine.medscape.com/article/1834870-overview
Fever may indicate a mild, self-limiting viral infection or a severe, life-threatening bacterial infection. The prognosis depends upon the cause and severity of the infection. […] The risk of invasive bacterial infection (IBI) such as bacteremia and bacterial meningitis is age dependent. […] The prevalence of a serious bacterial infection in infants younger than 3 months is approximately 6-10%, most often urinary tract infections (UTIs). […] Historically, children aged 3 months to 3 years with rectal temperatures of 38.5C (101.3F) or higher had a risk of 2-4% for occult bacteremia. […] The incidence of occult bacteremia in this population now ranges from 0.25% to 0.7%. […] The approach to the febrile child aged 3 months to 3 years consists of a targeted medical history, a complete physical examination, and the judicious use of the laboratory tests.
#10 Fever in the Infant and Toddler: Practice Essentials, Background, Neonates
https://emedicine.medscape.com/article/1834870-overview
Fever may indicate a mild, self-limiting viral infection or a severe, life-threatening bacterial infection. The prognosis depends upon the cause and severity of the infection. […] The risk of invasive bacterial infection (IBI) such as bacteremia and bacterial meningitis is age dependent. […] The prevalence of a serious bacterial infection in infants younger than 3 months is approximately 6-10%, most often urinary tract infections (UTIs). […] Historically, children aged 3 months to 3 years with rectal temperatures of 38.5C (101.3F) or higher had a risk of 2-4% for occult bacteremia. […] The incidence of occult bacteremia in this population now ranges from 0.25% to 0.7%. […] The approach to the febrile child aged 3 months to 3 years consists of a targeted medical history, a complete physical examination, and the judicious use of the laboratory tests.
#11 Fever in the Infant and Toddler: Practice Essentials, Background, Neonates
https://emedicine.medscape.com/article/1834870-overview
Fever may indicate a mild, self-limiting viral infection or a severe, life-threatening bacterial infection. The prognosis depends upon the cause and severity of the infection. […] The risk of invasive bacterial infection (IBI) such as bacteremia and bacterial meningitis is age dependent. […] The prevalence of a serious bacterial infection in infants younger than 3 months is approximately 6-10%, most often urinary tract infections (UTIs). […] Historically, children aged 3 months to 3 years with rectal temperatures of 38.5C (101.3F) or higher had a risk of 2-4% for occult bacteremia. […] The incidence of occult bacteremia in this population now ranges from 0.25% to 0.7%. […] The approach to the febrile child aged 3 months to 3 years consists of a targeted medical history, a complete physical examination, and the judicious use of the laboratory tests.
#12 Outcome prediction in pediatric fever in neutropenia: Development of clinical decision rules and external validation of published rules based on data from the prospective multicenter SPOG 2015 FN definition study | PLOS One
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0287233
Fever in neutropenia (FN) remains a serious complication of childhood cancer therapy. Clinical decision rules (CDRs) are recommended to help distinguish between children at high and low risk of severe infection. The aim of this analysis was to develop new CDRs for three different outcomes and to externally validate published CDRs. […] This analysis developed CDRs predicting bacteremia, SMC or SRE at presentation with FN. In addition, it identified six published CDRs that show some reproducibility. Validation of CDRs is fundamental to find the best balance between sensitivity and specificity, and will help to further improve management of FN. […] The CDRs for bacteremia and SRE used four characteristics (type of malignancy, severely reduced general condition, leucocyte count 0.3 G/L, bone marrow involvement), the CDR for SMC two characteristics (severely reduced general condition and platelet count 50 G/L).
#13 Outcome prediction in pediatric fever in neutropenia: Development of clinical decision rules and external validation of published rules based on data from the prospective multicenter SPOG 2015 FN definition study | PLOS One
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0287233
Fever in neutropenia (FN) remains a serious complication of childhood cancer therapy. Clinical decision rules (CDRs) are recommended to help distinguish between children at high and low risk of severe infection. The aim of this analysis was to develop new CDRs for three different outcomes and to externally validate published CDRs. […] This analysis developed CDRs predicting bacteremia, SMC or SRE at presentation with FN. In addition, it identified six published CDRs that show some reproducibility. Validation of CDRs is fundamental to find the best balance between sensitivity and specificity, and will help to further improve management of FN. […] The CDRs for bacteremia and SRE used four characteristics (type of malignancy, severely reduced general condition, leucocyte count 0.3 G/L, bone marrow involvement), the CDR for SMC two characteristics (severely reduced general condition and platelet count 50 G/L).
#14 Outcome prediction in pediatric fever in neutropenia: Development of clinical decision rules and external validation of published rules based on data from the prospective multicenter SPOG 2015 FN definition study | PLOS One
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0287233
Fever in neutropenia (FN) remains a serious complication of childhood cancer therapy. Clinical decision rules (CDRs) are recommended to help distinguish between children at high and low risk of severe infection. The aim of this analysis was to develop new CDRs for three different outcomes and to externally validate published CDRs. […] This analysis developed CDRs predicting bacteremia, SMC or SRE at presentation with FN. In addition, it identified six published CDRs that show some reproducibility. Validation of CDRs is fundamental to find the best balance between sensitivity and specificity, and will help to further improve management of FN. […] The CDRs for bacteremia and SRE used four characteristics (type of malignancy, severely reduced general condition, leucocyte count 0.3 G/L, bone marrow involvement), the CDR for SMC two characteristics (severely reduced general condition and platelet count 50 G/L).
#15 Outcome prediction in pediatric fever in neutropenia: Development of clinical decision rules and external validation of published rules based on data from the prospective multicenter SPOG 2015 FN definition study | PLOS One
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0287233
Performance of all three scores, when evaluated by internal cross-validation, has comparable or better predictive values than published CDRs. […] In conclusion, this analysis developed CDRs predicting bacteremia, SMC, and SRE in children with cancer presenting with FN. They are essentially in line with published CDRs and do not identify novel factors not previously described. In addition, external validation of 8 published CDRs identified 5 of them to show reproducible results for either sensitivity or for specificity in our setting. Only one showed reproducible results for both sensitivity and specificity, but with poor absolute indices of predictive performance.
#16 Fever in the Infant and Toddler: Practice Essentials, Background, Neonates
https://emedicine.medscape.com/article/1834870-overview
Fever may indicate a mild, self-limiting viral infection or a severe, life-threatening bacterial infection. The prognosis depends upon the cause and severity of the infection. […] The risk of invasive bacterial infection (IBI) such as bacteremia and bacterial meningitis is age dependent. […] The prevalence of a serious bacterial infection in infants younger than 3 months is approximately 6-10%, most often urinary tract infections (UTIs). […] Historically, children aged 3 months to 3 years with rectal temperatures of 38.5C (101.3F) or higher had a risk of 2-4% for occult bacteremia. […] The incidence of occult bacteremia in this population now ranges from 0.25% to 0.7%. […] The approach to the febrile child aged 3 months to 3 years consists of a targeted medical history, a complete physical examination, and the judicious use of the laboratory tests.
#17 Are children with prolonged fever at a higher risk for serious illness? A prospective observational study | Archives of Disease in Childhood
https://adc.bmj.com/content/108/8/632
A prolonged fever of five days or more is considered a warning sign for serious infection in childhood fever management guidelines. […] Prolonged fever is believed to be associated with serious bacterial infections (SBI) and with non-infectious and inflammatory conditions such as Kawasaki disease. […] In this multicentre prospective observational study, 10.6% of 35705 febrile children had a fever 5 days, with higher risk of SBI (8.4% vs 5.7%). […] Children with prolonged fever have a higher risk of SBI, warranting a careful clinical assessment and considerate diagnostic work, also with attention for rare but important non-infectious causes. […] In children with prolonged fever, there is a higher risk of SBI, warranting a careful clinical assessment and considerate diagnostic workup. […] Although rare, clinicians should consider the possibility of important non-infectious causes of prolonged fever.
#18 Predicting prolonged duration of fever in children: a cohort study in primary care
https://pmc.ncbi.nlm.nih.gov/articles/PMC4540397/
The derived prediction model indicates that only a few signs and symptoms are related to prolonged duration of fever. CRP has no additional value in this model. Overall, because the discriminative value of the model was low, the duration of fever cannot be accurately predicted. […] Although a longer duration of fever has no clear established predictive value for serious infections, it may lead to parental concern and, subsequently, increased medical care consumption. […] This study found several signs and symptoms to be related to a prolonged duration of fever. The overall predictive value was low, however, so the duration of fever cannot be predicted for an individual patient. […] The present study shows that, for children not directly referred to secondary care, the median duration of fever after consultation with the GPC is 1 day. The multivariate analysis showed that sore throat and palpable lymph nodes were predictive for a duration of fever 3 days. The predictive value of the model was considered low (AUC 0.64). CRP had no additive predictive value for prolonged duration of fever.
#19 Predicting prolonged duration of fever in children: a cohort study in primary care
https://pmc.ncbi.nlm.nih.gov/articles/PMC4540397/
The derived prediction model indicates that only a few signs and symptoms are related to prolonged duration of fever. CRP has no additional value in this model. Overall, because the discriminative value of the model was low, the duration of fever cannot be accurately predicted. […] Although a longer duration of fever has no clear established predictive value for serious infections, it may lead to parental concern and, subsequently, increased medical care consumption. […] This study found several signs and symptoms to be related to a prolonged duration of fever. The overall predictive value was low, however, so the duration of fever cannot be predicted for an individual patient. […] The present study shows that, for children not directly referred to secondary care, the median duration of fever after consultation with the GPC is 1 day. The multivariate analysis showed that sore throat and palpable lymph nodes were predictive for a duration of fever 3 days. The predictive value of the model was considered low (AUC 0.64). CRP had no additive predictive value for prolonged duration of fever.