Pediatric fever of uncertain source

From Tintinalli

Management of patients who are well-appearing, vaccinated, and no clinical source of fever

Age Group	Evaluation	Treatment
0-28d, ≥38C SBI incidence of ill appearing: 13%–21% if not ill appearing: <5%	CBC, blood Cx UA, Ucx CSF cell count, GS, Cx CXR (only if resp sx) Stool testing (if diarrhea present)	Admit Ampicillin 50mg/kg + (cefotaxime 50mg/kg or gentamicin 2.5mg/kg)
29-56d, ≥ 38.2 (100.8) (Philadelphia Protocol) SBI incidence of ill appearing: 13%–21% if not ill appearing: <5%	Same as for neonates	Discharge if: 1. WBC <15K but >5K and <20% bands 2. UA negative Admit and perform LP if above are not met Treat with CTX 50mg/kg (if CSF normal), 100mg/kg (if signs of meningitis)
57d-6mo, ≥38 Non-UTI SBI incidence is estimated to be negligible UTI is 3%–8%	UA and Ucx alone OR treat 57-90d using Philadelphia Protocol	Discharge if negative Treat UTI w/ cefixime 8mg/kg/d or cefpodoxime 10mg/kg/d divided into BID or cefdinir 14mg/kg/d x 7-10days as outpatient Admit and tx with CTX if fail criteria for d/c
57d-6mo, ≥39 (102.2) SBI incidence is estimated <1%; non-UTI SBI incidence is estimated to be negligible. UTI is 3%–8%	UA and Ucx alone OR UA and Ucx + CBC + blood cx	Discharge if negative Treat for UTI as above If WBC>15K consider treatment with CTX 50 mg/kg IV/IM, and follow-up in 24hr If WBC>20K consider CXR and CSF
6–36 mo Non-UTI SBI incidence is <0.4%  UTI in girls ≤8% UTI in boys (<12 mo) ≤ 2% Uncircumcised boys (1–2 y) remains 2%	UA and Ucx in: (girls 6-24mo) (circ 6-12mo) (uncirc 6-24mo)	Discharge if negative Treat for UTI as above as outpatient
>36mo	No further w/u is routinely necessary

Note: Preemies - Count age by estimated postconception date (not by actual delivery date) for 1st 90d

Harbor-UCLA Protocol

Background

• Medicine is an art as well as science, practice clinical judgment when using this guideline
• Preemies: Count age by estimated postconception date (not by actual delivery date) for 1st-90d
• If RSV+ or influenza+
  • Low risk of bacterial illness
  • Still some risk of concurrent UTI

0-28dy

Child Appearance	Work Up	Treatment	Disposition	Follow Up
T>=38 Toxic or Well	CBC Blood Cx UA, Ucx LP-CSF CXR^	Cefotaxime^^ 50-100 mg/kg Ampicillin 100-200 mg/kg Acyclovir^^^ 20 mg/kg	Admit	N/A

• ^CXR for (use clinical judgment):
  • Resp symptoms
  • Fever >48 hrs
  • Tachypnea
  • Decreased SaO2
• ^^Can use ceftriaxone 50-100 mg/kg, but concern for bilirubin displacement
• ^^^Acyclovir if:
  • HSV infection in baby or mother
  • CSF pleocytoisis
  • Concerning skin lesions
  • Seizures
  • Abnl LFTs

28dy-90dy

Appearance	Work Up	Treatment	Disposition	Follow Up
T>=38 + Toxic	CBC Blood Cx UA, Ucx LP-CSF CXR^	Cefotaxime^^ 50-100 mg/kg Ampicillin 100 mg/kg Acyclovir^^^ 20 mg/kg	Admit	NA
T>=38 + Well (Option 1)	CBC Blood Cx UA, UCx LP-CSF CXR^	Ceftriaxone (50mg/kg IM/IV)	If W/U (+) admit Outpatient^^^^	If W/U negative, meets outpt
T>=38 + Toxic (Option 2)	CBC Blood Cx UA, UCx CXR^	None For very well appearing 60-90 day olds (many would not use this option)	Outpatient^^^^

• ^CXR for (use clinical judgment):
  • Resp symptoms
  • Fever >48 hrs
  • Tachypnea
  • Decreased SaO2
• ^^Can use ceftriaxone 50-100 mg/kg, but concern for bilirubin displacement
• ^^^Acyclovir if:
  • HSV infection in baby or mother
  • CSF pleocytoisis
  • Concerning skin lesions
  • Seizures
  • Abnl LFTs
• ^^^^Outpatient

90dy-36mo

Appearance	Work Up	Treatment	Disposition	Follow Up
T>=39 + Toxic	CBC Blood Cx UA, UCx LP-CSF CXR^	Ceftriaxone (50-100mg/kg) OR Cefotaxime (50-100mg/kg) AND Consider Vanco (15mg/kg)^^^^	Admit	N/A
T>=39^^^^^ + Well + Prevnar^^	UA, UCx^^^ CXR^	If + W/U, oral abx	Outpatient
T>=39^^^^^ + Well + NO Prevnar^^	UA, UCx^^^ CBC CXR^	Ceftriaxone 50mg/kg if >15 WBC (also then consider BCx and LP)	Outpatient
T>=38-38.9 + Well	None Consider UA, CXR based on sx, etc	None	Outpatient	Return if worsening sx or fever persists >72hrs

• ^CXR for (use clinical judgment):
  • Resp symptoms
  • Fever >48 hrs
  • Tachypnea
  • Decreased SaO2
• ^^Prevnar = has 3 Prevnar or >=4 wks post 2nd Prevnar dose
• ^^^Urine workup for:
  • Circumcised males <6 months
  • Uncircumcised males <12 months
  • All females
• ^^^^Vancomycin if evidence of bacterial meningitis on CSF
• ^^^^^>=39.5 for 24-36mo

Work-Up Results

• WBC: 5-15, ANC <10k, <1,500 bands
• UA: (-)Gm Stain, (-) leuks, (-) nitrite, <5-10 wbc/hpf
• CSF: <8wbc, (-) Gm Stain
• When diarrhea present, <5 wbc

If low-risk criteria below not met, LP (if not done) and admit for inpt abx

Petechia

1. CBC
2. BCx
3. Ceftriaxone
4. LP depending on clinical

See Also

• UTI (Peds)
• Sepsis (Peds)
• Meningitis (Peds)
• Febrile Seizure

Source

• Tintinalli