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Fever Without Focus Management Birth to 3 Months

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Fever Without Focus Management Birth to 3 Months, Fever in the Newborn, Neonatal Fever

  1. Age <1 month: Perform a full Sepsis work-up
    1. Includes Lumbar Puncture
    2. Includes empiric antibiotics
    3. Serious Bacterial Infection may be present for Infants under age 1 month afebrile at clinical encounter, but febrile at home
      1. Brown (2004) CJEM 6(5): 343-8 [PubMed]
  2. Age 1-2 months: Evaluate infants at 1 to 2 months of age very carefully
    1. Perform a full Sepsis work-up unless exam, history and decision rules are completely reassuring
    2. Formal evaluation criteria (decision rules)
      1. Rochester Criteria for Febrile Infant 0 to 60 days
      2. Philadelphia Criteria for Febrile Infant 29-60 days
      3. Milwaukee Criteria for Febrile Infant 28-56 days
      4. Boston Criteria for Febrile Infant 28-89 days
  • Approach
  • Modifications To Protocol
  1. Toxic appearing infant under age 3 months
    1. See Toxic Findings Suggestive of Occult Bacteremia
    2. Treat per Neonatal Sepsis protocol or Pediatric Sepsis protocol
  2. RSV Bronchiolitis
    1. Age <30 days
      1. Admit for observation of apnea AND
      2. Perform Neonatal Sepsis work-up with labs (Lumbar Puncture is a clinical decision at this age with RSV)
    2. Age 30-60 days
      1. Admit all infants under age 60 days for observation of apnea
      2. Perform Neonatal Sepsis evaluation if indicated
    3. Age 60 days
      1. Non-toxic febrile infants at 60-90 days with Bronchiolitis do not need bacteremia work-up
      2. Blood Cultures and Lumbar Puncture are not needed
      3. Urinalysis and Urine Culture should still be performed (5% co-Incidence of UTI)
      4. Ralston (2011) Arch Pediatr Adolesc Med 165(10):951-6 [PubMed]
  3. Optional Protocol: Well appearing infant >21-28 days old (step-by-step protocol)
    1. Precautions
      1. Study focused on infants >21 days, but may be safer to apply to >28 day old infants
      2. Assumes well appearing infant
    2. Step 1: Obtain Urinalysis
      1. Positive Urinalysis for Leukocytes: Treat as intermediate risk (complete Neonatal Sepsis workup)
    3. Step 2: Obtain Procalcitonin, CBC, CRP (if Urinalysis negative)
      1. Negative markers: Treat as low risk with close interval follow-up
      2. Positive markers: Treat as intermediate risk (complete Neonatal Sepsis workup)
        1. Procalcitonin >0.5 ng/ml OR
        2. CRP >20 OR
        3. Absolute Neutrophil Count >10,000
    4. References
      1. Claudius and Behar in Herbert (2016) EM:Rap 16(12): 1-2
      2. Gomez (2016) Pediatrics 138(2) +PMID: 27382134 [PubMed]
  4. Optional Protocol
    1. Precautions
      1. Study focused on infants younger than 60 days old with many exclusion criteria
    2. Low Risk Criteria (all must be present)
      1. Urinalysis negative
      2. Absolute Neutrophil Count (ANC) <4000/ul
      3. Procalcitonin 0.5 ng/ml
    3. Interpretation
      1. Identified 98.8% of ill children requiring additional Sepsis workup
    4. References
      1. Claudius and Behar in Herbert (2019) EM:Rap 19(7): 7
  • Indications
  1. Nontoxic appearing young infant under age 3 months
    1. See Toxic Findings Suggestive of Occult Bacteremia
  2. Fever (over 38 C or 100.4 F)
  3. No known infectious source
  1. Age <13 days
  2. History of exposure to serious infection
  3. Fever > 39.5 to 40.0 degrees Celsius
  4. White Blood Cell Count
    1. Markers
      1. Leukopenia <5,000
        1. Serious Bacterial Infection risk PPV >44%
        2. Sepsis risk increased at <4.1k
      2. Leukocytosis >15k
        1. Serious Bacterial Infection risk PPV >44%
        2. Sepsis risk increased at >20k
      3. Absolute Neutrophil Count (ANC) > 10,000
        1. Serious Bacterial Infection risk PPV >71%
      4. References
        1. Bressan (2010) Pediatr Infect Dis J 29(3): 227-32 [PubMed]
    2. Precautions
      1. Normal WBC Count does not rule-out Meningitis
        1. Bonsu (2003) Ann Emerg Med 41:206-14 [PubMed]
      2. Normal WBC Count does not rule-out bacteremia
        1. Bonsu (2003) Ann Emerg Med 42:216-25 [PubMed]
  5. C-Reactive Protein (CRP) >2 mg/dl
    1. Bilavsky (2009) Acta Paediatr 98(11): 1776-80 [PubMed]
  6. Urinalysis positive
    1. Positive Findings
      1. Leukocyte esterase positive
      2. Nitrite positive
      3. White Blood Cells >5 cells/hpf on spun sample
    2. Precaution
      1. Catheterized urine or suprapubic aspirate for all samples
        1. Bag urine has 85% False Positive Rate
        2. Fineell (2011) Pediatrics 128(3):e749-70 [PubMed]
      2. Urine Culture all samples
        1. Urine dipstick False Negative Rate: 12%
        2. Gorelick (1999) Pediatrics 104(5): e54 [PubMed]
  7. References
    1. Bachur (2001) Pediatrics 108(2):311-16 [PubMed]
  • Management
  • Age <1 month old or toxic appearance
  1. See Fever Without Focus for signs of toxicity
  2. Admit for assessment as for Neonatal Sepsis
  3. Labs
    1. See Fever Without Focus Labs
  4. Protocol: Antibiotics
    1. Do not use Ceftriaxone in under age 1 month (due to Kernicterus risk)
    2. Consider adjunctive use of Acyclovir (if Neonatal HSV at increased risk)
    3. IV antibiotic protocol 1 (use both)
      1. Ampicillin 100 to 200 mg/kg IV or IM divided every 6 hours AND
      2. Gentamicin 2.5 mg/kg IV or IM every 8 hours (adjust based on serum levels)
    4. IV antibiotic protocol 2 (use both)
      1. Ampicillin 100 to 200 mg/kg IV or IM divided every 6 hours AND
      2. Cefotaxime 50 mg/kg IV every 8 hours
  5. Protocol: Acyclovir Indications (added to antibiotics above)
    1. Age 2-11 days old
    2. Maternal Genital Herpes
    3. Seizures
    4. Cutaneous Vesicles
    5. Elevated Liver Function Tests
    6. Coagulopathy
    7. CSF Pleocytosis with negative Gram Stain
  6. Disposition
    1. Observe for 48 hours
  • Management
  • Age 1-3 month old
  1. Labs
    1. See Fever Without Focus Labs
    2. Complete Blood Count with differential
    3. Urinalysis and Urine Culture
    4. Blood Cultures (esp. if antibiotics given)
    5. Other labs to consider as indicated
      1. CSF Studies (esp. if antibiotics given)
      2. Stool Studies
      3. Chest XRay
  2. Criteria for home observation (24 hour follow-up)
    1. Must have non-toxic appearance and be at low risk of Sepsis
      1. See Toxic Findings Suggestive of Occult Bacteremia
      2. See risk factors above
      3. See Fever Without Focus for signs of toxicity
      4. Term infant without chronic disease or hospitalizations
      5. See Rochester Criteria for Febrile Infant 0 to 60 days
      6. See Philadelphia Criteria for Febrile Infant 29-60 days
      7. See Milwaukee Criteria for Febrile Infant 28-56 days
      8. See Boston Criteria for Febrile Infant 28-89 days
    2. Must be reliable for follow-up
      1. Reliable care takers
      2. Transportation and telephone available
      3. Willingness to return in 24 hours
    3. Lab criteria
      1. White Blood Cell Count <15,000 cells/mm
      2. Absolute Neutrophil Count <10,000 cells/mm
      3. Other labs normal (e.g. UA, CSF)
      4. Cerebrospinal fluid (CSF)
        1. White Blood Cell Count <8
        2. Gram Stain Negative
  3. Protocol: Criteria for home management are met
    1. Consider Ceftriaxone 50 mg/kg (up to 1 gram) IM
    2. Follow-up appointment within 24 hours
  4. Protocol: Criteria for home not met
    1. See Neonatal Sepsis protocol
    2. Meningitis not suspected
      1. Ceftriaxone 50 mg/kg/day IV or IM divided every 12 to 24 hours
    3. Meningitis is a concern
      1. Ceftriaxone 100 mg/kg/day IV or IM divided every 12 to 24 hours
    4. Listeria or Enterococcus is a concern
      1. Add Ampicillin 100-200 mg/kg/day IV or IM divided every 6 hours to Ceftriaxone (dosed as above)
  • References
  1. Claudius and Behar in Herbert (2019) EM:Rap 19(7): 7
  2. Herman (2015) Crit Dec Emerg Med 29(12):14-19
  3. Latessa (2012) AAFP Board Review Express, San Jose
  4. Wang and Claudius in Herbert (2013) EM:Rap 13(6): 1-2
  5. Baraff (1993) Pediatrics 92:1-12 [PubMed]
  6. Baraff (2000) Ann Emerg Med 36:602-14 [PubMed]
  7. Hamilton (2013) Am Fam Physician 87(4): 254-60 [PubMed]
  8. Luszczak (2001) Am Fam Physician 64(7):1219-26 [PubMed]
  9. Sur (2007) Am Fam Physician 75:1805-11 [PubMed]