Emergency Department Guideline

Infant Fever 29-60 Days

Inclusion criteria
● Full term (≥ 37 weeks) infant 29-60 days with no underlying medical condition (including
significant NICU course)
● Fever ≥ 38.0º C or reliable history of fever

Triage considerations
● Triage level 2
● Vital signs with BP; rectal temp for all
● Place on continuous pulse ox if concerns
● Notify physician and place on CR monitor if evidence of instability (bradycardia,
capillary refill > 3 seconds, skin is mottled, ill appearing child, or depressed LOC)
● Discuss with attending whether to draw labs and perform urine cath before or after full
MD H&P

Laboratory studies
● All infants receive:
o CBC/diff Abnormal lab definitions
o CRP and/or PCT
o Blood culture CSF
o Cath urinalysis with micro and mandatory culture > 9 WBCs OR
(no reflex) > 10,000 RBCs without
o RSV, influenza rapid testing in season clear history of traumatic
● If suspect HSV or dehydration: tap
o CMP Any PMNs on cell count
● If hemodynamically unstable, purpura, or other concern UA
for frank sepsis: Positive nitrite OR
o PT/INR, PTT, fibrinogen, VBG, lactate Positive leukocyte
o Perform LP (but do not delay antibiotics) esterase OR
● Perform LP on stable infants if: > 10 WBC/hpf
o Concern for HSV (vesicular lesions, seizure, CBC
reported maternal or family history) WBC < 5,000 OR
o Abnormal CBC WBC > 15,000
o Consider for abnormal UA, abnormal CXR, poor
feeding, irritability, lethargy, bulging fontanel or other clinical concerns
o Ill-appearing
This UMMCH Guideline addresses only key points of care for the specific population; it is not intended to be a comprehensive practice guideline. These recommendations result from review of literature and practices current at
the time of their formulation. This Guideline does not preclude using care modalities proven efficacious in studies published subsequent to the current revision of this document. This document is not intended to impose standards
of care preventing selective variances from the recommendations to meet the specific and unique requirements of individual patients. Adherence to this Statement is voluntary. The clinician in light of the individual circumstances
presented by the patient must make the ultimate judgment regarding the priority of any specific procedure or course of action.
Infant Fever 29-60 Days
October 2017
Division of Pediatric Emergency Medicine
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 ● If LP performed, send CSF for:
o Cell count
o Total protein
o Glucose
o Gram stain and culture
o HSV PCR if vesicular lesions, seizure, abnormal CSF, reported maternal or family
history of HSV
o Enterovirus PCR if summer
● If LP is attempted but minimal or no CSF obtained:
o If low quantity, bacterial culture is highest priority
o If multiple attempts unsuccessful, treat as if abnormal and give antibiotics as
below
● If giving acyclovir (consider deferring to floor but
must be done 8 hours within giving acyclovir):
o Unroof vesicle, if present:
▪ Send viral transport media swab (red
tube with fine metal swab and pink
fluid) for HSV PCR and culture
o Eye swab, rectal swab, mouth swab for HSV
PCR and culture
o Add-on LFTs

Imaging
● CXR if respiratory symptoms or signs
● If >10,000 RBCs without clear history of traumatic tap, seizure, or other neurologic
concerns, consider head CT for evaluation for trauma or other neurologic processes

Medications/interventions
● Infants with any high risk features (abnormal CBC, UA, CXR, septic appearance):
o Ceftriaxone 50 mg/kg IV/IM
● If CSF returns abnormal:
o Repeat ceftriaxone 50 mg/kg IV/IM x 1 (to total 100 mg/kg)
o Consider vancomycin 15 mg/kg IV
o Consider acyclovir 20 mg/kg IV
● If hemodynamically unstable or GPC on CSF Gram stain:
o Give vancomycin 15 mg/kg IV
● Even if CSF normal, if vesicular lesions, seizure, or reported maternal or family history of
HSV:
o Acyclovir 20 mg/kg IV
● If positive rapid influenza or if significant clinical concerns (high fever, cough, family
history, epidemic, etc):
o Tamiflu 3 mg/kg PO
● If evidence of dehydration or hemodynamic instability:
o NS bolus, 20 ml/kg; repeat as needed. If instability not improving, refer to sepsis
guideline

Consultations
This UMMCH Guideline addresses only key points of care for the specific population; it is not intended to be a comprehensive practice guideline. These recommendations result from review of literature and practices current at
the time of their formulation. This Guideline does not preclude using care modalities proven efficacious in studies published subsequent to the current revision of this document. This document is not intended to impose standards
of care preventing selective variances from the recommendations to meet the specific and unique requirements of individual patients. Adherence to this Statement is voluntary. The clinician in light of the individual circumstances
presented by the patient must make the ultimate judgment regarding the priority of any specific procedure or course of action.
Infant Fever 29-60 Days
October 2017
Division of Pediatric Emergency Medicine
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 ● Subspecialty services as needed for patients with underlying conditions
● Hospitalist for admission if indicated

Reassessments
● VS q1h

Differential diagnosis
● Sepsis
● Bacteremia
● UTI
● Viral or bacterial meningitis
● Pneumonia
● Disseminated HSV
● Viral illness
● Spurious fever

Discharge or admission criteria

● PICU
o Hemodynamic instability
o Evidence of DIC
o Ongoing seizure activity
o Severe respiratory compromise
● Inpatient floor
o Abnormal CSF
o Abnormal UA
o Abnormal CXR
o Concern for HSV
o Dehydration or poor PO
o Other clinical or family concerns
o Barriers to obtaining follow-up within 24 hours (e.g. transportation)
● Discharge to home
o Good PO intake
o Stable respiratory status
o All labs low risk
▪ OR high risk CBC, other labs low risk, CSF obtained and ceftriaxone
given
o Follow-up within 24 hours available
▪ Recommend pediatrician or repeat ED visit in 24 hours for culture check,
second dose ceftriaxone if LP performed and first dose given

Quality measures
● Antibiotics, if indicated, started within 1 hour
● All infants with blood and urine cultures
● LP attempt before antibiotics, if given for elevated WBC (not necessary if given for
pneumonia or UTI)

This UMMCH Guideline addresses only key points of care for the specific population; it is not intended to be a comprehensive practice guideline. These recommendations result from review of literature and practices current at
the time of their formulation. This Guideline does not preclude using care modalities proven efficacious in studies published subsequent to the current revision of this document. This document is not intended to impose standards
of care preventing selective variances from the recommendations to meet the specific and unique requirements of individual patients. Adherence to this Statement is voluntary. The clinician in light of the individual circumstances
presented by the patient must make the ultimate judgment regarding the priority of any specific procedure or course of action.
Infant Fever 29-60 Days
October 2017
Division of Pediatric Emergency Medicine
~3~
 Febrile Infant
29 to 60 days of age
Bacterial Infection Checklist
YES NO
O O Born at less than 37 weeks gestation?
O O History of prior hospitalization?
Full Sepsis Evaluation Is patient O O Prolonged newborn nursery course?
HSV Risk Assessment No well O O Does the child have a chronic illness?
Admit appearing? O O Received antibiotics prior to this visit?
O O Is either the CRP or PCT elevated?
O O Are bands >1500/cc?
Yes O O History of unexplained
hyperbilirubinemia?
Obtain:
Herpes Simplex Virus (HSV) Checklist • UA and urine culture If any “Yes” proceed to High Risk Bacterial
YES NO • CBC with diff infection recommendations
O O Maternal history of HSV (prior disease or active • Blood Culture
lesions)? • Resp viral testing (if resp sx)
O O History of seizures or seizures during the evaluation • CRP (or PCT)
O O Vesicles on skin exam (including scalp)
O O CSF with pleocytosis for age?
Complete Bacterial Ambulatory Discharge Disposition Checklist
If any “Yes” proceed to HSV High Risk recommendation
Infection Checklist
YES NO
O O Are the parents comfortable with
monitoring their child at home?
O O Do the parents have reliable means of
Is the Receiving communication from the
Perform lumbar puncture patient at low or high risk hospital/ED?
High risk
Administer antibiotics for a bacterial O O Can bacterial culture results be followed
infection? daily by the hospital/ED?
O O Can the patient follow-up with their PCP
in 24 hours?
O O Is the UA completely normal?
Complete HSV Checklist
If any “No” admit the patient.

Low risk
Is the
patient at low or high
risk for an HSV
infection? WBC < 5,000/cc UA positive for nitrites, LE
No Yes
or > 15,000/cc or WBC>5/HPF

High risk
Yes
No
Obtain HSV surface and vesicle Administer antibiotics
cultures and CSF PCR Perform lumbar puncture

Administer antibiotics Admit patient

Administer acyclovir
Low risk (inpatient) **
pending PCR and Should the patient
viral culture results be discharged?

No Yes
* Cons ider switching to inpatient if expected stay >24hrs and
clinically warranted.
Admit patient ** Target discharge goals are 3 0hrs for low risk patients and
Register to Discharge patient
(inpatient) ** 42hrs for others with a negative workup. observation for 24hrs*

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