Pediatric fever of uncertain source: Difference between revisions
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==Background==
==Background==
===Facts and Figures from ACEP's Clinical Policy on Pediatric Fevers===
*Fever accounts for 30% of pediatric visits
*7% of patients < 2 years old with fever have PNA, however the etiology (viral/bacterial) or even the presence of pneumonia has low inter-observer reliability even among pediatric radiologists
*Children <3 months are immunocompromised (e.g. poor opsonization, poor IgG response to encapsulated bacteria, macrophage and neutrophil dysfunction, bone marrow insufficiency)
*4% Prevalence of UTI with common other sources of fever (OM, viral URI, et cetera)
*Concern is for missing a serious bacterial infection (SBI)
*1.5-2% background prevalence of asymptomatic bacteruria in healthy afebrile controls
*0.3% Rate of occult bactremia with healthy, well-appearing child who has a fever 2-24 months
*0.3% of previously well children aged 3-36 months who have a fever without a source will develop significant sequelae, 0.03% will develop sepsis or meningitis


=== Concomitant RSV infection ===
===Epidemiology and Risk===
*In RSV+ (by PCR) neonates aged 0-28 days, 6.1% had UTIs and 3.7% were bactremic; there was no difference in rates of SBI between RSV+ and RSV- neonates in a large prospective multicenter study entailing 1,248 children
{| class="wikitable"
*RSV+ infants aged 29-60 days, the SBI rate was 5.5%, all of which were UTIs
| align="center" style="background:#f0f0f0;"|'''Age'''
 
| align="center" style="background:#f0f0f0;"|'''0-14 days'''
==Tintinalli Textbook Protocol==
| align="center" style="background:#f0f0f0;"|'''14-28 days'''
 
| align="center" style="background:#f0f0f0;"|'''28-60 days (pre vaccine)'''
- '''Management of patients who are well-appearing, ''vaccinated'', and no clinical source of fever'''  
| align="center" style="background:#f0f0f0;"|'''28-60 days (post vaccine)'''
 
| align="center" style="background:#f0f0f0;"|'''60-90 days'''
{| class="wikitable"
| align="center" style="background:#f0f0f0;"|'''> 90 days'''
|-
|-
| Age Group
| [[Meningitis]]/SBI Prevalence ||1/10||1/20||1/100||1/1000||1/1000-10,000||> 1/10,000
| Evaluation
|}
| Treatment
*Serious bacterial illness (SBI) includes UTI, meningitis, pneumonia, bacteremia
|-
*7% of patients <2 years old with fever have [[pneumonia]], however the etiology (viral/bacterial) or even the presence of pneumonia has low inter-observer reliability even among pediatric radiologists<ref>ACEP's Clinical Policy on Pediatric Fever. Clinical Policy for Children Younger Than Three Years Presenting to the Emergency Department With Fever. Annuals of Emergency Medicine 2003 42. 530-545</ref>
|
*4% Prevalence of [[UTI]] with common other sources of fever ([[OM]], viral [[URI]], etc)<ref>ACEP's Clinical Policy on Pediatric Fever. Clinical Policy for Children Younger Than Three Years Presenting to the Emergency Department With Fever. Annuals of Emergency Medicine 2003 42. 530-545</ref>
0-28d, ≥38C
*0.3% of previously well children aged 3-36 months who have a fever without a source will develop significant sequelae, 0.03% will develop sepsis or meningitis<ref>ACEP's Clinical Policy on Pediatric Fever. Clinical Policy for Children Younger Than Three Years Presenting to the Emergency Department With Fever. Annuals of Emergency Medicine 2003 42. 530-545</ref>


SBI incidence of ill appearing: 13%–21%  
===Concomitant Respiratory Viral Infection===
*Relatively high coincidence of [[RSV]], [[enterovirus]], and [[paraflu]] with bacteremia (and UTIs), so positive lab test for these viruses should not change testing and management plan<ref>Greenes, D.S.M., & Harper, M. B.M. (1999). Low risk of bacteremia in febrile children with recognizable viral syndromes. Pediatric Infectious Disease Journal, 18(3), 258-261.</ref>
**[[RSV]]+ neonates aged 0-28 days, 3.7% were bactremic (and 6.1% had [[UTI]]s)
**RSV+ infants aged 29-60 days, (5.5% had [[UTI]]s)
*There is a low coincidence of [[influenza]] with SBI, so postivie lab test for this virus may change testing and management plan (i.e. lower risk of concurrent bacterial illness)<ref>Greenes, D.S.M., & Harper, M. B.M. (1999). Low risk of bacteremia in febrile children with recognizable viral syndromes. Pediatric Infectious Disease Journal, 18(3), 258-261.</ref>


if not ill appearing: &lt;5%
==Clinical Features==
*[[Acute fever|Febrile]]
**Defined as [[Celsius Fahrenheit Temperature Conversion|temperature]] ≥38°C (100.4°F).
**Peripheral temperature is not clinically accurate and central measurements are the preferred means of determining fever.
**Parental report of confirmed fever at home (i.e. via thermometer), even with no fever in ED, has rates of SBIs high as 4.7% (0-28 day range)<ref>Serious bacterial infections in neonates presenting afebrile with history of fever Ramgopal S, Walker LW, Tavarez MM, et al. Pediatrics. 2019;144(2):e20183964.</ref>


|
==Differential Diagnosis==
CBC, blood Cx
{{Pediatric fever DDX}}


UA, Ucx
==Evaluation & Management==
*Preemies: Count age by estimated postconception date (not by actual delivery date) for 1st-90d


CSF cell count, GS, Cx
===0-7 Days===
 
''For all infants (toxic and well-appearing)''
CXR (only if resp sx)
 
Stool testing (if diarrhea present)
 
|
Admit
 
Ampicillin 50mg/kg + (cefotaxime 50mg/kg or gentamicin 2.5mg/kg)


{| class="wikitable"
|-
| '''Child Appearance'''
| '''Work Up'''
| '''Treatment'''
| '''Disposition & Follow-up'''
| '''Comments'''
|-
|-
| '''Temperature ≥38°'''
'''Toxic or Well'''
|  
|  
29-56d, ≥ 38.2 (100.8) (Philadelphia Protocol)
*CBC
 
*Blood cultures
<br>SBI incidence of ill appearing: 13%–21%
*[[Urinalysis]], Urine culture
 
*[[LP]]-CSF
if not ill appearing: &lt;5%
*[[CXR]]
 
*+/- Stool studies (if diarrhea)
<br>
 
| Same as for neonates
|  
|  
Discharge if:  
{{Pediatric fever antibiotics 0-28)}}
| Admit
| SBI incidence
*Ill appearing: 13%–21%
*Not ill appearing: <5%
|}


1. WBC &lt;15K but &gt;5K and &lt;20% bands
{{Pediatric fever acyclovir indications}}


2. UA negative
Note:
*CXR is optional if no resp sx and another source identified
*LP is necessary even if another source identified due to immature blood-brain barrier
*Do not give ceftriaxone to children <28d as may cause hyperbilirubinemia


Admit and perform LP if above are not met
===8-21 Days<ref>Evaluation and Management of Well-Appearing Febrile Infants 8 to 60 Days Old Robert H. Pantell, Kenneth B. Roberts, William G. Adams, Benard P. Dreyer, Nathan Kuppermann, Sean T. O'Leary, Kymika Okechukwu and Charles R. Woods; Subcommittee On Febrile Infants Pediatrics July 2021, e2021052228; DOI: https://doi.org/10.1542/peds.2021-052228 </ref>===
 
*For toxic infants, treat for sepsis and admit
Treat with [[ceftriaxone]] 50mg/kg (if CSF normal), 100mg/kg (if signs of meningitis)
*For well-appearing infants:
[[File:Peds fever 8-21 days (2.0).png|thumb|8-21 day algorithm]]


{| class="wikitable"
|-
|-
|  
| '''Child Appearance'''
57d-6mo, ≥38
| '''Work Up'''
 
| '''Treatment'''
Non-UTI SBI incidence is estimated to be negligible
| '''Disposition & Follow-up'''
 
| '''Comments'''
<span class="Apple-style-span" style="line-height: 17px">UTI is 3%–8%</span>&nbsp;
 
<br>
 
|
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 [[ceftriaxone]] if fail criteria for d/c
 
|-
|-
|  
| Temperature ≥38°C
57d-6mo, ≥39 (102.2)


SBI incidence is estimated &lt;1%;
Well-appearing


non-UTI SBI incidence is estimated to be negligible.
No evident source of infection
 
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&gt;15K&nbsp;consider treatment with [[ceftriaxone]] 50 mg/kg IV/IM, and follow-up in 24hr
 
If WBC&gt;20K&nbsp;consider CXR and CSF


'''Increased HSV risk'''
|
*[[Urinalysis]], Urine culture
*Blood culture
*Inflammatory markers (IMs) - may obtain
*[[LP]]-CSF
*HSV studies
|
*Initiate parenteral antimicrobial(s), including [[Acyclovir]]
|
*Observe in hospital
*If pathogen or source identified → Treat infection
*If all culture results negative at 24-36 hours AND HSV PCR negative → Discontinue antimicrobials; may discharge. Manage for duration of illness.
|
Consider HSV if:
*Maternal h/o genital HSV lesions or fever 48 hrs before to 48 hrs after delivery
*Vesicles, mucous membrane ulcers
*[[Seizures]]
*Hypothermia
*[[CSF]] pleocytosis + negative gram stain
*Leukopenia
*Thrombocytopenia
*Elevated ALT
|-
|-
|  
| Temperature ≥38°C
&nbsp;6–36 mo


Non-UTI SBI incidence is &lt;0.4%&nbsp;
Well-appearing


UTI in girls ≤8%
No evident source of infection


UTI in boys (&lt;12 mo) ≤ 2%
'''No increased HSV risk'''
 
|
Uncircumcised boys (1–2 y) remains 2%
*[[Urinalysis]], Urine culture
 
*Blood culture
|  
*Inflammatory markers (IMs) - may obtain
UA and Ucx in:
*[[LP]]-CSF
 
|
(girls 6-24mo)
*Initiate parenteral antimicrobial(s)
 
|
(circ 6-12mo)
*Observe in hospital
 
*If pathogen or source identified → Treat infection
(uncirc 6-24mo)
*If all culture results negative at 24-36 hours → Discontinue antimicrobials; may discharge. Manage for duration of illness.
 
|
|  
Discharge if negative
 
Treat for UTI as above as outpatient
 
|-
| &gt;36mo
| No further w/u is routinely necessary
| <br>
|}
|}


Note: Preemies - Count age by estimated postconception date (not by actual delivery date) for 1st 90d
===22-28 Days<ref>Evaluation and Management of Well-Appearing Febrile Infants 8 to 60 Days Old Robert H. Pantell, Kenneth B. Roberts, William G. Adams, Benard P. Dreyer, Nathan Kuppermann, Sean T. O'Leary, Kymika Okechukwu and Charles R. Woods; Subcommittee On Febrile Infants Pediatrics July 2021, e2021052228; DOI: https://doi.org/10.1542/peds.2021-052228 </ref>===
*For toxic infants, treat for sepsis and admit
*For well-appearing infants:
[[File:Peds fever 22-28 days (2.0).PNG|22-28 day algorithm]]


== 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  ===


{| class="wikitable"
{| class="wikitable"
|-
|-
| '''Child Appearance'''  
| '''Child Appearance'''
| '''Work Up'''  
| '''Work Up'''
| '''Treatment'''  
| '''Treatment'''
| '''Disposition'''  
| '''Disposition & Follow-up'''
| '''Follow Up'''
| '''Comments'''
|-
| Temperature ≥38°C
Well-appearing
No source of infection
'''Abnormal IMs'''
'''CSF pleocytosis or uninterpretable'''
|
*[[Urinalysis]], Urine culture (bladder catheterization or SPA if UA positive)
*Blood culture
*Inflammatory markers (IMs)
*Perform [[LP]](11b) - CSF
|
*Administer IV antibiotics
|
*Observe in hospital
*If pathogen or source identified → Treat infection
*If all cultures negative at 24-36 hours and HSV PCR negative (if sent) → Discontinue IV antibiotics; may discharge. Follow for duration of illness.
| Abnormal Inflammatory Markers:
*Temp > 38.5
*[[Procalcitonin]] > 0.5 ng/mL
*CRP ≥ 20 mg/L
*ANC > 4500 or 5200
|-
| Temperature ≥38°C
Well-appearing
No evident source of infection
'''Abnormal IMs'''
'''No CSF pleocytosis''' (or CSF not obtained)
|
*[[Urinalysis]], Urine culture (bladder catheterization or SPA if UA positive)
*Blood culture
*Inflammatory markers (IMs)
*Perform [[LP]] - CSF (may not be obtained)
|
*If observation at home: Administer IV antibiotics
*If observation in hospital: May administer IV antibiotics
|
*If observation at home: Observe at home. Reassess in 24 hours.
*If observation in hospital: Observe in hospital).
*If pathogen or source identified → Treat infection
*If all cultures negative at 24-36 hours and HSV PCR negative (if sent) → Discontinue IV antibiotics; may discharge. Follow for duration of illness.
|
|-
| Temperature ≥38°C
Well-appearing
No evident source of infection
'''Normal IMs'''
'''LP performed, CSF obtained, CSF pleocytosis or traumatic'''
|
*[[Urinalysis]], Urine culture (bladder catheterization or SPA if UA positive)
*Blood culture
*Inflammatory markers (IMs)
*May perform [[LP]] - CSF
|
*May administer IV antibiotics
|
*Observe in hospital
*If pathogen or source identified → Treat infection
*If all cultures negative at 24-36 hours and HSV PCR negative (if sent) → Discontinue IV antibiotics; may discharge. Follow for duration of illness.
|
|-
|-
| '''Temp ≥38°'''  
| Temperature ≥38°C
'''Toxic or Well'''
Well-appearing
 
No evident source of infection
|  
'''Normal IMs'''
#CBC
'''LP performed, CSF obtained, no CSF pleocytosis/not traumatic''' OR '''CSF not obtained''' OR '''LP not performed'''
#Blood Cx
|
#UA, Ucx
*[[Urinalysis]], Urine culture (bladder catheterization or SPA if UA positive)
#LP-CSF  
*Blood culture
#CXR
*Inflammatory markers (IMs)
|  
*May perform [[LP]]
#Cefotaxime 50-100 mg/kg
|
#Ampicillin 100-200 mg/kg
*If observation at home: Administer IV antibiotics
#Acyclovir^ 20 mg/kg
*If observation in hospital: May administer IV antibiotics
 
*If LP performed but CSF not obtained, or LP not performed: May administer IV antibiotics); Observe in hospital
| Admit
|
| N/A
*If observation at home: Observe at home. Reassess in 24 hours.
*If observation in hospital: Observe in hospital.
*If pathogen or source identified → Treat infection
*If all cultures negative at 24-36 hours and HSV PCR negative (if sent) → Discontinue IV antibiotics; may discharge. Follow for duration of illness.
|
|}
|}


^Acyclovir if:  
===29-60 Days<ref>Evaluation and Management of Well-Appearing Febrile Infants 8 to 60 Days Old Robert H. Pantell, Kenneth B. Roberts, William G. Adams, Benard P. Dreyer, Nathan Kuppermann, Sean T. O'Leary, Kymika Okechukwu and Charles R. Woods; Subcommittee On Febrile Infants Pediatrics July 2021, e2021052228; DOI: https://doi.org/10.1542/peds.2021-052228 </ref>===
*HSV infection in baby or mother
*For toxic infants, treat for sepsis and admit
*CSF pleocytoisis
*For well-appearing infants:
*Concerning skin lesions
*Seizures
*Abnl LFTs


 
[[File:Peds fever 29-60 (2.0).PNG|thumb|29-60 day algorithm]]
 
=== 28dy-90dy  ===


{| class="wikitable"
{| class="wikitable"
|-
|-
| '''Appearance'''  
| '''Child Appearance'''
| '''Work Up'''  
| '''Work Up'''
| '''Treatment'''  
| '''Treatment'''
| '''Disposition'''  
| '''Disposition & Follow-up'''
| '''Follow Up'''
| '''Comments'''
|-
|-
| '''Temp≥38° + Toxic'''
| Temperature ≥38°C
|
Well-appearing
#CBC
No evident source of infection
#Blood Cx
#UA, Ucx
#LP-CSF
#CXR^


|  
'''Abnormal IMs'''
#Cefotaxime 50-100 mg/kg
|
#Ampicillin 100 mg/kg
*[[Urinalysis]] (obtain for all)
#Acyclovir 20 mg/kg
*Blood culture (obtain for all)
 
*Inflammatory markers (IMs) (obtain for all)
| Admit
*Send bladder catheterization or SPA urine culture if positive urinalysis (15)
| NA
*May perform [[LP]] (18a)
|
*If CSF result is positive: Administer parenteral antimicrobial(s) (19a)
*If CSF result is negative and either urinalysis negative or positive: May administer parenteral or oral antimicrobial(s) (19b)
*If CSF not available or uninterpretable: Administer parenteral antimicrobial(s) (19a)
|
*If CSF result is positive: Observe closely in hospital (20a)
*If CSF result is negative and either urinalysis negative or positive: May observe closely in hospital or at home (20b,d)
*If CSF not available or uninterpretable: May observe closely in hospital or at home (20b)
| Abnormal Inflammatory Markers:
*Temp > 38.5
*[[Procalcitonin]] > 0.5 ng/mL
*CRP ≥ 20 mg/L
*ANC > 4500 or 5200
|-
|-
|  
| Temperature ≥38°C
'''Temp≥°38 + Well'''
Well-appearing
 
No evident source of infection
'''(Option 1)'''
 
|
#CBC
#Blood Cx
#UA, UCx
#LP-CSF
#CXR^


'''Normal IMs'''
'''Positive urinalysis result'''
|
*[[Urinalysis]] (obtain for all)
*Blood culture (obtain for all)
*Inflammatory markers (IMs) (obtain for all)
*Send bladder catheterization or SPA urine culture (15)
*Need not perform [[LP]] (18b)
|
*Administer oral antimicrobial(s) (19c)
|
*May observe closely at home
*Follow-up in 12 to 24 hours (20d)
|
|
#Ceftriaxone (50mg/kg IM/IV)
|
If W/U (+) admit
Outpatient
| If W/U negative, meets outpt
|-
|-
|  
| Temperature ≥38°C
'''T&gt;=38 + Toxic'''
Well-appearing
No evident source of infection


'''(Option 2)'''
'''Normal IMs'''
 
'''Negative urinalysis result'''
|  
|
#CBC
*[[Urinalysis]] (obtain for all)
#Blood Cx
*Blood culture (obtain for all)
#UA, UCx
*Inflammatory markers (IMs) (obtain for all)
#CXR^
*Need not perform [[LP]] (18b)
 
|
|  
*Need not administer antimicrobial(s) (19d)
#None
|
 
*Observe closely at home (20c)
For very well appearing 60-90 day olds (many would not use this option)
*Follow-up within 24-36 hours (20c)
 
|
| Outpatient
|1-2 days
|}
|}


*CXR for (use clinical judgment):
'''At 24 to 36 hours follow-up:'''
**Resp symptoms
*If pathogen or source identified at 24-36 hours AND source limited to urine → Complete treatment with oral antimicrobials (21c); Discharge hospitalized infants (21b); Manage for duration of illness
**Fever >48 hrs
*If pathogen or source identified at 24-36 hours AND source NOT limited to urine → Treat infection (21d)
**Tachypnea
*If NO pathogen or source identified at 24-36 hours → Discontinue antimicrobials if administered (21a); Discharge hospitalized infants (21b); Manage for duration of illness
**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
 
=== 90dy-36mo  ===


===60 Days - 36 Months<ref>Jaskiewicz, J.A., McCarthy, C.A., Richardson, A.C., White, K.C., Fisher, D.J., Powell, K. R., et al. (1994). Febrile infants at low risk for serious bacterial infection-an appraisal of the Rochester criteria and implications for management. Pediatrics 94(3), 390-396.</ref>===
{| class="wikitable"
{| class="wikitable"
|-
|-
Line 286: Line 322:
| '''Work Up'''  
| '''Work Up'''  
| '''Treatment'''  
| '''Treatment'''  
| '''Disposition'''
| '''Disposition & Follow-Up'''  
| '''Follow Up'''
|-
|-
| '''T>=39 + Toxic'''
| '''T≥38° + Toxic'''
|  
|  
#CBC  
*CBC  
#Blood Cx
*Blood cultures
#UA, UCx
*[[Urinalysis]], urine culture
#LP-CSF  
*[[LP]]-CSF  
#CXR^
*[[CXR]]^
 
|  
|  
[[Ceftriaxone]] (50-100mg/kg)
{{Pediatric fever antibiotics 90dy-36mo}}
 
OR
 
Cefotaxime (50-100mg/kg)
 
AND
 
Consider [[vancomycin]] (15mg/kg)^^^^
 
| Admit  
| Admit  
| N/A
|-
|
'''T>=39°C + Well + 3 Prevnar or ≥4 wks post 2nd Prevnar dose'''
|
#UA, UCx^^^
#CXR^
|
If + W/U, oral abx
| Outpatient
|
|-
|-
| '''T≥39°C + Well + Non-complete [[Prevnar]]'''
(No [[Prevnar]] or <4 weeks post 1st [[Prevnar]] dose)
|  
|  
'''T>=39°C + Well + Non complete Prevnar'''
*[[Urinalysis]], Urine culture
 
*CBC  
|
*+/- CXR
#UA, Urine culture
| If WBC(+):
#CBC  
*[[Ceftriaxone]] 50mg-100mg/kg (also then consider [[blood culture]] and [[LP]], especially in <6mo old)
#CXR
| Outpatient (24 hour follow-up)
 
|  
[[Ceftriaxone]] 50mg/kg if &gt;15 WBC (also then consider [[BCx]] and [[LP]])
 
| Outpatient  
|
|-
|-
| '''T>=38-38.9°C + Well'''
| '''T≥39°C + Well + [[Prevnar]]'''
(2 [[Prevnar]] or ≥4 weeks post 1st [[Prevnar]] dose)
|  
|  
None
*Urine workup (UA, urine culture) for:
 
Consider UA, CXR based on symptoms, etc
 
|
None
 
| Outpatient
| Return if worsening sx or fever persists >72hrs
|}
 
*Chest Xray should be ordered based on clinical judgment and:
**Resp symptoms
**Fever >48 hrs
**Tachypnea
**Decreased SaO2
 
*Refer to the [[Vaccination Schedule]] for information regarding Pneumococcal (Prevnar) vaccine
 
*Urine workup for:
**Circumcised males <6 months
**Circumcised males <6 months
**Uncircumcised males <12 months
**Uncircumcised males <12 months
**All females
**All females
*+/- CXR
| Treat [[cystitis]] or [[pneumonia]] if postitive
| Outpatient (48hour follow up)
|-
| '''T≥38-38.9°C + Well'''
| Consider UA, CXR based on symptoms, etc
| Treat [[cystitis]] or [[pneumonia]] if positive
| Outpatient (48-72 hour follow-up)<ref>Baker, M.D., Bello, L.M., & Avner, J.R. (1993). Outpatient management without antibiotics of fever in selected infants. New England Jouranl of Medicine, 329(20), 1437-1441.</ref>
|-
|}
{{Pediatric fever CXR indications}}


===Work-Up Results===
*Non-UTI SBI incidence of <.4% in children >6 mo
*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


===Purpura or Petechia===
==Low Risk Lab Criteria==
*Skin changes are often the most concerning finding in a pediatric fever
''If low-risk criteria below not met, then perform the LP (if not done) and admit for inpatient antibiotics''<ref> Smitherman, H.F. & Macias, C.G. (2014). Evaluation and management of fever in the neonate and young infant (less than three months of age) [Electronic Version]. UpToDate,Teach, S.J., Kaplan, SL, Wiley, JF.</ref><ref>Dagan, R. Sofer, S., Phillip, M., & Shachak, E. (1988). Ambulatory care of febrile infants younger than 2 months of age classified as being at low risk for having serous bacterial infections. Journal of Pediatrics, 112(3), 355-360.</ref>
====Differential====
===CBC===
*[[Meningitis (Peds)]]
*WBC 5-15 /mm<sup>3</sup>
*[[HSP]]
*Absolute Band count <1500 /mm<sup>3</sup>
*[[ITP]]
*Procalcitonin ≤0.5 ng/mL
*[[Microangiopathic Hemolytic Anemia (MAHA)]]
*ANC ≤4000/mm<sup>3</sup>
*[[TTP]]
===Urinalysis===
*[[HUS]]
*Clear
====Workup====
*Neg Nitrate and Leukocyte esterase
#CBC
*WBC <10/high powered field
#Blood Cultures
===CSF===
#Basic Metabolic Panel (evaluating creatine)
*Studies should include WBC, protein, glucose, Gram stain, and culture for bacteria. Consider viral studies (HSV).
#Chest Xray if pulmonary symptoms
====0-28 days====
#[[Lumbar Puncture]] depending on clinical findings and if not thrombocytopenic
*WBC: 0-22/mm<sup>3</sup>
*Protein: <100mg/dL
====>29 days====
*WBC 0-7/mm<sup>3</sup>
*Protein: 15-25mg/dL


== See Also  ==
==Additional Management==
*[[Fever]]
===Initial Empiric Antibiotics for Well-Appearing Infants===
*[[FUO (Peds)]]
{{Infant fever well antibiotics}}
*[[UTI (Peds)]]
{{Acetaminophen pediatric dosing chart}}
*[[Sepsis (Peds)]]
*[[Meningitis (Peds)]]
*[[Febrile Seizure]]
*[[Antibiotics By Diagnosis (Peds)]]


== External Links ==
==See Also==
*[[Acute fever]]
*[[Fever of unknown origin (peds)]]
*[[Urinary tract infection (peds)]]
*[[Sepsis (peds)]]
*[[Meningitis (peds)]]
*[[Febrile seizure]]
*[[PECARN Febrile Infant]]


==External Links==
*[http://www.pemed.org/blog/2011/10/9/fever-of-unknown-source-part-1.html PEM ED Algorithm for Pediatric Fever]
*[http://www.pemed.org/blog/2011/10/9/fever-of-unknown-source-part-1.html PEM ED Algorithm for Pediatric Fever]
*[http://ddxof.com/pediatric-fever/ DDxOf: Pediatric Fever]


== Source s==
==References==
*Clinical Policy for Children Younger Than Three Years Presenting to the Emergency Department With Fever. Annuals of Emergency Medicine 2003 42. 530-545
<references/>
*Risk of Serious Bacterial Infection in Young Febrile Infants With Respiratory Syncytial Virus Infections. Levine et all. PEDIATRICS Vol. 113 No. 6 June 1, 2004 pp. 1728 -1734


[[Category:Peds]]
[[Category:Pediatrics]]
[[Category:ID]]

Latest revision as of 02:45, 13 April 2026

Background

  • Fever accounts for 30% of pediatric visits
  • Children <3 months are immunocompromised (e.g. poor opsonization, poor IgG response to encapsulated bacteria, macrophage and neutrophil dysfunction, bone marrow insufficiency)
  • Concern is for missing a serious bacterial infection (SBI)

Epidemiology and Risk

Age 0-14 days 14-28 days 28-60 days (pre vaccine) 28-60 days (post vaccine) 60-90 days > 90 days
Meningitis/SBI Prevalence 1/10 1/20 1/100 1/1000 1/1000-10,000 > 1/10,000
  • Serious bacterial illness (SBI) includes UTI, meningitis, pneumonia, bacteremia
  • 7% of patients <2 years old with fever have pneumonia, however the etiology (viral/bacterial) or even the presence of pneumonia has low inter-observer reliability even among pediatric radiologists[1]
  • 4% Prevalence of UTI with common other sources of fever (OM, viral URI, etc)[2]
  • 0.3% of previously well children aged 3-36 months who have a fever without a source will develop significant sequelae, 0.03% will develop sepsis or meningitis[3]

Concomitant Respiratory Viral Infection

  • Relatively high coincidence of RSV, enterovirus, and paraflu with bacteremia (and UTIs), so positive lab test for these viruses should not change testing and management plan[4]
    • RSV+ neonates aged 0-28 days, 3.7% were bactremic (and 6.1% had UTIs)
    • RSV+ infants aged 29-60 days, (5.5% had UTIs)
  • There is a low coincidence of influenza with SBI, so postivie lab test for this virus may change testing and management plan (i.e. lower risk of concurrent bacterial illness)[5]

Clinical Features

  • Febrile
    • Defined as temperature ≥38°C (100.4°F).
    • Peripheral temperature is not clinically accurate and central measurements are the preferred means of determining fever.
    • Parental report of confirmed fever at home (i.e. via thermometer), even with no fever in ED, has rates of SBIs high as 4.7% (0-28 day range)[6]

Differential Diagnosis

Pediatric fever

Evaluation & Management

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

0-7 Days

For all infants (toxic and well-appearing)

Child Appearance Work Up Treatment Disposition & Follow-up Comments
Temperature ≥38°

Toxic or Well

  • CBC
  • Blood cultures
  • Urinalysis, Urine culture
  • LP-CSF
  • CXR
  • +/- Stool studies (if diarrhea)
 Admit SBI incidence
  • Ill appearing: 13%–21%
  • Not ill appearing: <5%

^Acyclovir if:

  • HSV infection in baby or mother
  • CSF pleocytoisis
  • Concerning skin lesions
  • Seizures
  • Abnormal LFTs

Note:

  • CXR is optional if no resp sx and another source identified
  • LP is necessary even if another source identified due to immature blood-brain barrier
  • Do not give ceftriaxone to children <28d as may cause hyperbilirubinemia

8-21 Days[7]

  • For toxic infants, treat for sepsis and admit
  • For well-appearing infants:
8-21 day algorithm
Child Appearance Work Up Treatment Disposition & Follow-up Comments
Temperature ≥38°C

Well-appearing

No evident source of infection

Increased HSV risk

  • Urinalysis, Urine culture
  • Blood culture
  • Inflammatory markers (IMs) - may obtain
  • LP-CSF
  • HSV studies
  • Initiate parenteral antimicrobial(s), including Acyclovir
  • Observe in hospital
  • If pathogen or source identified → Treat infection
  • If all culture results negative at 24-36 hours AND HSV PCR negative → Discontinue antimicrobials; may discharge. Manage for duration of illness.

Consider HSV if:

  • Maternal h/o genital HSV lesions or fever 48 hrs before to 48 hrs after delivery
  • Vesicles, mucous membrane ulcers
  • Seizures
  • Hypothermia
  • CSF pleocytosis + negative gram stain
  • Leukopenia
  • Thrombocytopenia
  • Elevated ALT
Temperature ≥38°C

Well-appearing

No evident source of infection

No increased HSV risk

  • Urinalysis, Urine culture
  • Blood culture
  • Inflammatory markers (IMs) - may obtain
  • LP-CSF
  • Initiate parenteral antimicrobial(s)
  • Observe in hospital
  • If pathogen or source identified → Treat infection
  • If all culture results negative at 24-36 hours → Discontinue antimicrobials; may discharge. Manage for duration of illness.

22-28 Days[8]

  • For toxic infants, treat for sepsis and admit
  • For well-appearing infants:

22-28 day algorithm


Child Appearance Work Up Treatment Disposition & Follow-up Comments
Temperature ≥38°C

Well-appearing No source of infection Abnormal IMs CSF pleocytosis or uninterpretable

  • Urinalysis, Urine culture (bladder catheterization or SPA if UA positive)
  • Blood culture
  • Inflammatory markers (IMs)
  • Perform LP(11b) - CSF
  • Administer IV antibiotics
  • Observe in hospital
  • If pathogen or source identified → Treat infection
  • If all cultures negative at 24-36 hours and HSV PCR negative (if sent) → Discontinue IV antibiotics; may discharge. Follow for duration of illness.
 Abnormal Inflammatory Markers:
  • Temp > 38.5
  • Procalcitonin > 0.5 ng/mL
  • CRP ≥ 20 mg/L
  • ANC > 4500 or 5200
Temperature ≥38°C

Well-appearing No evident source of infection Abnormal IMs No CSF pleocytosis (or CSF not obtained)

  • Urinalysis, Urine culture (bladder catheterization or SPA if UA positive)
  • Blood culture
  • Inflammatory markers (IMs)
  • Perform LP - CSF (may not be obtained)
  • If observation at home: Administer IV antibiotics
  • If observation in hospital: May administer IV antibiotics
  • If observation at home: Observe at home. Reassess in 24 hours.
  • If observation in hospital: Observe in hospital).
  • If pathogen or source identified → Treat infection
  • If all cultures negative at 24-36 hours and HSV PCR negative (if sent) → Discontinue IV antibiotics; may discharge. Follow for duration of illness.
Temperature ≥38°C

Well-appearing No evident source of infection Normal IMs LP performed, CSF obtained, CSF pleocytosis or traumatic

  • Urinalysis, Urine culture (bladder catheterization or SPA if UA positive)
  • Blood culture
  • Inflammatory markers (IMs)
  • May perform LP - CSF
  • May administer IV antibiotics
  • Observe in hospital
  • If pathogen or source identified → Treat infection
  • If all cultures negative at 24-36 hours and HSV PCR negative (if sent) → Discontinue IV antibiotics; may discharge. Follow for duration of illness.
Temperature ≥38°C

Well-appearing No evident source of infection Normal IMs LP performed, CSF obtained, no CSF pleocytosis/not traumatic OR CSF not obtained OR LP not performed

  • Urinalysis, Urine culture (bladder catheterization or SPA if UA positive)
  • Blood culture
  • Inflammatory markers (IMs)
  • May perform LP
  • If observation at home: Administer IV antibiotics
  • If observation in hospital: May administer IV antibiotics
  • If LP performed but CSF not obtained, or LP not performed: May administer IV antibiotics); Observe in hospital
  • If observation at home: Observe at home. Reassess in 24 hours.
  • If observation in hospital: Observe in hospital.
  • If pathogen or source identified → Treat infection
  • If all cultures negative at 24-36 hours and HSV PCR negative (if sent) → Discontinue IV antibiotics; may discharge. Follow for duration of illness.

29-60 Days[9]

  • For toxic infants, treat for sepsis and admit
  • For well-appearing infants:
29-60 day algorithm
Child Appearance Work Up Treatment Disposition & Follow-up Comments
Temperature ≥38°C

Well-appearing No evident source of infection

Abnormal IMs

  • Urinalysis (obtain for all)
  • Blood culture (obtain for all)
  • Inflammatory markers (IMs) (obtain for all)
  • Send bladder catheterization or SPA urine culture if positive urinalysis (15)
  • May perform LP (18a)
  • If CSF result is positive: Administer parenteral antimicrobial(s) (19a)
  • If CSF result is negative and either urinalysis negative or positive: May administer parenteral or oral antimicrobial(s) (19b)
  • If CSF not available or uninterpretable: Administer parenteral antimicrobial(s) (19a)
  • If CSF result is positive: Observe closely in hospital (20a)
  • If CSF result is negative and either urinalysis negative or positive: May observe closely in hospital or at home (20b,d)
  • If CSF not available or uninterpretable: May observe closely in hospital or at home (20b)
 Abnormal Inflammatory Markers:
  • Temp > 38.5
  • Procalcitonin > 0.5 ng/mL
  • CRP ≥ 20 mg/L
  • ANC > 4500 or 5200
Temperature ≥38°C

Well-appearing No evident source of infection

Normal IMs Positive urinalysis result

  • Urinalysis (obtain for all)
  • Blood culture (obtain for all)
  • Inflammatory markers (IMs) (obtain for all)
  • Send bladder catheterization or SPA urine culture (15)
  • Need not perform LP (18b)
  • Administer oral antimicrobial(s) (19c)
  • May observe closely at home
  • Follow-up in 12 to 24 hours (20d)
Temperature ≥38°C

Well-appearing No evident source of infection

Normal IMs Negative urinalysis result

  • Urinalysis (obtain for all)
  • Blood culture (obtain for all)
  • Inflammatory markers (IMs) (obtain for all)
  • Need not perform LP (18b)
  • Need not administer antimicrobial(s) (19d)
  • Observe closely at home (20c)
  • Follow-up within 24-36 hours (20c)

At 24 to 36 hours follow-up:

  • If pathogen or source identified at 24-36 hours AND source limited to urine → Complete treatment with oral antimicrobials (21c); Discharge hospitalized infants (21b); Manage for duration of illness
  • If pathogen or source identified at 24-36 hours AND source NOT limited to urine → Treat infection (21d)
  • If NO pathogen or source identified at 24-36 hours → Discontinue antimicrobials if administered (21a); Discharge hospitalized infants (21b); Manage for duration of illness

60 Days - 36 Months[10]

Appearance Work Up Treatment Disposition & Follow-Up
T≥38° + Toxic Admit
T≥39°C + Well + Non-complete Prevnar

(No Prevnar or <4 weeks post 1st Prevnar dose)

If WBC(+): Outpatient (24 hour follow-up)
T≥39°C + Well + Prevnar

(2 Prevnar or ≥4 weeks post 1st Prevnar dose)

  • Urine workup (UA, urine culture) for:
    • Circumcised males <6 months
    • Uncircumcised males <12 months
    • All females
  • +/- CXR
 Treat cystitis or pneumonia if postitive Outpatient (48hour follow up)
T≥38-38.9°C + Well Consider UA, CXR based on symptoms, etc Treat cystitis or pneumonia if positive Outpatient (48-72 hour follow-up)[11]
  • Consider CXR for:
    • Respiratory symptoms
    • Fever >48 hrs
    • Tachypnea
    • Hypoxia
  • Non-UTI SBI incidence of <.4% in children >6 mo

Low Risk Lab Criteria

If low-risk criteria below not met, then perform the LP (if not done) and admit for inpatient antibiotics[12][13]

CBC

  • WBC 5-15 /mm3
  • Absolute Band count <1500 /mm3
  • Procalcitonin ≤0.5 ng/mL
  • ANC ≤4000/mm3

Urinalysis

  • Clear
  • Neg Nitrate and Leukocyte esterase
  • WBC <10/high powered field

CSF

  • Studies should include WBC, protein, glucose, Gram stain, and culture for bacteria. Consider viral studies (HSV).

0-28 days

  • WBC: 0-22/mm3
  • Protein: <100mg/dL

>29 days

  • WBC 0-7/mm3
  • Protein: 15-25mg/dL

Additional Management

Initial Empiric Antibiotics for Well-Appearing Infants

Neonatal Antibiotics by Source[14]

Suspected Infection Source 8-21 Days Old 22-28 Days Old 29-60 Days Old
UTI
  • Ampicillin IV or IM (150 mg/kg per day divided q8) AND either:
No source identified
  • Ampicillin IV or IM (150 mg/kg per day divided q8) AND either:
Bacterial meningitis
  • Ampicillin IV or IM (300 mg/kg per day divided q6) AND
  • Ceftazidime IV or IM (150 mg/kg per day divided q8)
  • Ampicillin IV or IM (300 mg/kg per day divided q6) AND
  • Ceftazidime IV or IM (150 mg/kg per day divided q8)


Acetaminophen Pediatric Dosing Chart

Weight (kg) Weight (lbs) Age Dosage (mg)
3-4 6-11 0-3 mo 40
5-7 12-17 4-11 mo 80
8-10 18-23 1-2 y 120
11-15 24-35 2-3 y 160
16-21 36-47 4-5 y 240
22-26 48-59 6-8 y 320
27-32 60-71 9-10 y 400
33-43 72-95 11 y 480
Dosage can be given q6 hours

See Also

External Links

References

  1. ↑ ACEP's Clinical Policy on Pediatric Fever. Clinical Policy for Children Younger Than Three Years Presenting to the Emergency Department With Fever. Annuals of Emergency Medicine 2003 42. 530-545
  2. ↑ ACEP's Clinical Policy on Pediatric Fever. Clinical Policy for Children Younger Than Three Years Presenting to the Emergency Department With Fever. Annuals of Emergency Medicine 2003 42. 530-545
  3. ↑ ACEP's Clinical Policy on Pediatric Fever. Clinical Policy for Children Younger Than Three Years Presenting to the Emergency Department With Fever. Annuals of Emergency Medicine 2003 42. 530-545
  4. ↑ Greenes, D.S.M., & Harper, M. B.M. (1999). Low risk of bacteremia in febrile children with recognizable viral syndromes. Pediatric Infectious Disease Journal, 18(3), 258-261.
  5. ↑ Greenes, D.S.M., & Harper, M. B.M. (1999). Low risk of bacteremia in febrile children with recognizable viral syndromes. Pediatric Infectious Disease Journal, 18(3), 258-261.
  6. ↑ Serious bacterial infections in neonates presenting afebrile with history of fever Ramgopal S, Walker LW, Tavarez MM, et al. Pediatrics. 2019;144(2):e20183964.
  7. ↑ Evaluation and Management of Well-Appearing Febrile Infants 8 to 60 Days Old Robert H. Pantell, Kenneth B. Roberts, William G. Adams, Benard P. Dreyer, Nathan Kuppermann, Sean T. O'Leary, Kymika Okechukwu and Charles R. Woods; Subcommittee On Febrile Infants Pediatrics July 2021, e2021052228; DOI: https://doi.org/10.1542/peds.2021-052228
  8. ↑ Evaluation and Management of Well-Appearing Febrile Infants 8 to 60 Days Old Robert H. Pantell, Kenneth B. Roberts, William G. Adams, Benard P. Dreyer, Nathan Kuppermann, Sean T. O'Leary, Kymika Okechukwu and Charles R. Woods; Subcommittee On Febrile Infants Pediatrics July 2021, e2021052228; DOI: https://doi.org/10.1542/peds.2021-052228
  9. ↑ Evaluation and Management of Well-Appearing Febrile Infants 8 to 60 Days Old Robert H. Pantell, Kenneth B. Roberts, William G. Adams, Benard P. Dreyer, Nathan Kuppermann, Sean T. O'Leary, Kymika Okechukwu and Charles R. Woods; Subcommittee On Febrile Infants Pediatrics July 2021, e2021052228; DOI: https://doi.org/10.1542/peds.2021-052228
  10. ↑ Jaskiewicz, J.A., McCarthy, C.A., Richardson, A.C., White, K.C., Fisher, D.J., Powell, K. R., et al. (1994). Febrile infants at low risk for serious bacterial infection-an appraisal of the Rochester criteria and implications for management. Pediatrics 94(3), 390-396.
  11. ↑ Baker, M.D., Bello, L.M., & Avner, J.R. (1993). Outpatient management without antibiotics of fever in selected infants. New England Jouranl of Medicine, 329(20), 1437-1441.
  12. ↑ Smitherman, H.F. & Macias, C.G. (2014). Evaluation and management of fever in the neonate and young infant (less than three months of age) [Electronic Version]. UpToDate,Teach, S.J., Kaplan, SL, Wiley, JF.
  13. ↑ Dagan, R. Sofer, S., Phillip, M., & Shachak, E. (1988). Ambulatory care of febrile infants younger than 2 months of age classified as being at low risk for having serous bacterial infections. Journal of Pediatrics, 112(3), 355-360.
  14. ↑ Evaluation and Management of Well-Appearing Febrile Infants 8 to 60 Days Old Robert H. Pantell, Kenneth B. Roberts, William G. Adams, Benard P. Dreyer, Nathan Kuppermann, Sean T. O'Leary, Kymika Okechukwu and Charles R. Woods; Subcommittee On Febrile Infants Pediatrics July 2021, e2021052228; DOI: https://doi.org/10.1542/peds.2021-052228
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