The child with HIV and a fever

Submitted by Paul Decle on Sat, 06/08/2011

Authors: Guide information
Andrew Riordan

Date of preparation: August 2003
Date reviewed: May 2007
Next review date: July 2010

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These guidelines are for the child with a fever but no other symptoms and signs.

Children with HIV have a considerably increased risk of bacterial infections. General principles are: give antibiotics earlier, in higher doses for longer courses

Note the stage of the child’s illness. The more severely immunosuppressed the more likely to have opportunistic infection with minimal signs and serious pathology. Look in notes for recent letters and CD4 count. CD4 < 10%, means severely immunosuppressed. Above 25% is classified as having no evidence of immunosuppression. Severely immunosuppressed children (especially infants in whom CD4 counts are an unreliable guide) are at risk of Pneumocystis pneumonia:check their O2 saturation in air for hypoxia.

Take a good history of the acute illness and examine the child thoroughly. Ask about travel history. Get past history from notes – parents often vague/reluctant historians of past illness. If the child has had proven bacterial infection before – could be recurrence of that infection. Check contact history ?TB ?incubating VZV. Check no recent immunisations given (MMR can cause fever up to 2 weeks later).
Particularly look for:-

a). Septicaemia

Mainly pneumococcal (or in children recently arrived from sub-Saharan Africa etc, salmonella sp) – symptoms/signs may be masked. If at all toxic or unwell; admit to hospital, take FBC, CRP, blood cultures (and malaria films if in endemic region within last 12 months), biochemistry including hepatic enzymes and renal function, ?venous blood gases, and treat with iv Ceftriaxone (80 mg/kg/day) or Cefotaxime (50mg/kg/dose qds). Add Flucloxacillin (25 mg/kg/dose qds) if any skin infection/abscess. A high neutrophil count is a useful guide, but cannot be relied on.

b). ENT infections:

Sinusitis. Take throat swabs – viral and bacterial. Treat with Augmentin duo (0.3 ml/kg per dose bd; MAX 10 ml bd for children up to 12 yr olds) for 7-10 days and chase results.

Cervical lymphadenitis. If mild treat with oral augmentin. If large may need iv antibiotics – Ceftriaxone or Cefotaxime and Flucloxacillin. If fluctuant involve surgeons.

c). Skin infections and abscesses.
Take Swabs. Treat with Augmentin.

d). Oral infections.
Look for Candida and/or herpes simplex. Take swabs – viral and bacterial. Treat with oral Fluconazole (3-4 mg/kg/day) and/or oral Valaciclovir. If child is having difficulty swallowing, consider endoscopy and biopsy for oesophagitis.

e). UTI
Send Urine culture and treat with Augmentin.
f).
If prescribing oral/iv antibiotics warn child / carers to look out for oral candidiasis. If this develops, give Miconazole Oral gel. If this fails to control it, give Fluconazole (2-3 mg/kg/day OD, just whilst on antibiotics).

g).
Consider other occult sites of infection: bone / joints / abdomen / disseminated systemic infection (MAI / CMV / measles with no rash, etc). Discuss with HIV paediatrician if fever does not respond to initial treatment.,/p>

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