FEBRILE ILLNESS ● 1/4

ASSESSMENT AND INITIAL MANAGEMENT

• Fever, in a child aged <5 yr, usually indicates underlying infection
• infants aged <3 months, low temperature could indicate infection
• consider vaccination induced fever in infants aged <3 months
• Parental perceptions of fever are usually accurate and must be taken seriously

IDENTIFYING RISK OF SERIOUS ILLNESS

Three stages of clinical assessment
1. Identify life-threatening features [utilising Airway, Breathing, Circulation (hydration) and Disability
assessment]
2. Assess risk of serious illness (see Traffic light system for assessment) − can be used with Paediatric
Early Warning Score (PEWS)
3. Attempt to identify source of infection/features of specific serious conditions. If child has a learning
disability, take this into account when interpreting the traffic light system

Traffic light system for assessment

Low risk Intermediate risk High risk
Colour • Skin, lips and • Pallor reported by carer • Pale, mottled, ashen or blue
tongue normal
• Responds to • Not responding normally • No response to social cues
normal social to social cues • Looks ill
cues • Wakes only with • Unrousable/doesn’t stay
• Content/smiles prolonged stimulation awake after rousing
Activity
• Stays awake/ • Decreased activity • Weak, high pitched or
wakes quickly • No smile continuous cry
• Strong normal
cry/settled/smiles
• Normal • Nasal flare • Grunting/nasal flare
• Tachypnoea • Tachypnoea
• respiratory rate ≥50/min • respiratory rate >60/min (any
(aged <1 yr) age)
Breathing
• respiratory rate ≥40/min • Chest wall recession
(aged >1 yr) (moderate/severe)
• SpO2 ≤95%
• Crackles on auscultation
• Normal skin and • Dry mucous membranes • Reduced skin turgor
eyes • Poor feeding (infants)
• Moist mucous
Age Heart rate (bpm)
Circulation membranes
<1 yr >160
and
1–2 yr >150
hydration
2–5 yr >140
• CRT ≥3 sec
• Reduced urine output
• No amber/red • Temperature ≥39°C (aged • Temperature ≥38°C (aged
features 3–6 months) <3 months)
• Rigors • Non-blanching rash
• Fever ≥5 days • Bulging fontanelle
Other • New lump >2 cm diameter • Neck stiffness
• Swelling of joint/limb • Status epilepticus
• Not using a limb/weight • Focal neurological signs
bearing • Focal seizures
• Bilious vomiting

Issue 8 124
Issued: December 2018
Expires: December 2020
 FEBRILE ILLNESS ● 2/4

Child aged <3 months Assess: look for life-threatening, Child aged ≥3 months
traffic light and specific diseases
symptoms and signs – see Traffic
light system for assessment
• Observe and monitor:
• temperature (is it post
vaccination?)
• heart rate If all green If any amber If any red features
• respiratory rate features and no features and no and no diagnosis
amber or red diagnosis reached reached

• Perform:
• full blood count • Perform • Perform: • Perform:
• C-reactive protein microscopy and • microscopy and • blood culture
• blood culture culture culture full blood • full blood count
• urine microscopy and • Assess for count • microscopy and
culture for urinary tract symptoms and • blood culture culture C-
infection signs of • C-reactive protein reactive protein
• if respiratory signs pneumonia or procalcitonin • Consider
present, CXR • Do not perform • if fever >39°C and (guided by
• if diarrhoea present, routine blood white blood cell clinical
stool culture tests or CXR count >20 x 10 /L
9
assessment):
– CXR • lumbar puncture
• if child aged <1 yr, in children of all
• Admit, perform lumbar consider lumbar ages
puncture and start puncture (guided • CXR
• If no diagnosis
parenteral antibiotics if by clinical irrespective of
reached,
child: assessment) white blood cell
manage child at
• aged <1 month home with count and body
• aged 1–3 months, appropriate temperature
appearing unwell care advice • serum
• aged 1–3 months, with • Advise electrolytes
white blood cell count parents/carers • blood gas
9
of <5 or >15 x 10 /L when to seek
Wherever possible, further attention
perform lumbar from healthcare
puncture before services
administration of
antibiotics

• Consider admission according to clinical and social circumstances and treat – see Subsequent
management
• If child does not require admission but no diagnosis has been reached, provide parent/carer with
verbal and/or written information on warning symptoms and how to access further healthcare
• e.g. signs of dehydration: sunken fontanelle/eyes, dry mouth, no tears; non-blanching rash
• Liaise with healthcare professionals (including out-of-hours) to ensure parent/carer has direct access
for further assessment of child

Observations
• Measure and record in all febrile children:
• temperature
− aged <4 weeks: electronic thermometer in the axilla
− aged >4 weeks: infrared tympanic or electronic thermometer in the axilla
• respiratory rate, heart rate, capillary refill time
• signs of dehydration: skin turgor, respiratory pattern, weak pulse, cool extremities
• travel history
• Re-assess all children with amber or red features within 1–2 hr

Issue 8 125
Issued: December 2018
Expires: December 2020
FEBRILE ILLNESS ● 3/4
IMMEDIATE TREATMENT
Antipyretic treatment
• Tepid sponging not recommended
• Dress child normally
• If child appears distressed or unwell, give either paracetamol or ibuprofen
• do not routinely administer both drugs at the same time with the sole aim of reducing fever or preventing
febrile seizures
• Alternate if distress persists or recurs before next dose due

Antibiotics
• Do not prescribe oral antibiotics to children with fever without apparent source
• if aged >3 months consider admission and observation with/without investigations

Signs of shock
• Increased respiratory and heart rate, cold peripheries, prolonged CRT, pallor/mottled,
drowsy/agitated/confused
• Give immediate IV fluid bolus of sodium chloride 0.9% 20 mL/kg. Give additional boluses as necessary
• If signs of shock, SpO2 <92% or clinically indicated, prescribe oxygen
• Urgent senior support: discuss with PICU
• See Sepsis (including meningococcal) guideline

SUBSEQUENT MANAGEMENT
• Serious bacterial infection suspected:
• shock
• unrousable
• meningococcal disease
• aged <1 month
• aged 1–3 months with a white blood cell count <5 or >15 x 109/L
• aged 1–3 months appearing unwell
• Cefotaxime 50 mg/kg slow IV bolus 6-hrly (see BNFc for neonatal doses)
• When patient is stable change to once daily ceftriaxone:
• see contraindications (hyperbilirubinaemia etc.) in BNFc
• RSV/flu: assess for serious illness/UTI
• If rates of antibacterial resistance significant, refer to local policy
• See Sepsis (including meningococcal) and Meningitis guidelines

Symptoms and signs of specific diseases

Meningococcal disease
• Non-blanching rash with ≥1 of the following:
• ill-looking child
• lesions >2 mm in diameter (purpura)
• CRT ≥3 sec
• neck stiffness

Meningitis
• Neck stiffness
• Bulging fontanelle
• Decreased level of consciousness
• Convulsive status epilepticus

Herpes simplex encephalitis

• Focal neurological signs
• Focal seizures
• Decreased level of consciousness

Pneumonia
• Tachypnoea, measured as:
• aged <1 yr: respiratory rate ≥50 breaths/min
• aged >1 yr: respiratory rate >40 breaths/min
• Crackles in the chest

Issue 8 126
Issued: December 2018
Expires: December 2020
FEBRILE ILLNESS ● 4/4
• Nasal flaring
• Chest indrawing
• Cyanosis
• SpO2 ≤95%

Urinary tract infection

• Vomiting (in children aged >3 months)
• Poor feeding
• Lethargy
• Irritability
• Abdominal pain or tenderness
• Urinary frequency or dysuria
• Offensive urine or haematuria

Septic arthritis/osteomyelitis
• Swelling of a limb or joint
• Not using an extremity
• Non weight bearing

Kawasaki disease
• Fever lasting >5 days and ≥4 of the following:
• bilateral conjunctival injection
• change in upper respiratory tract mucous membranes (e.g. injected pharynx, dry cracked lips or
strawberry tongue)
• change in peripheral extremities (e.g. oedema, erythema or desquamation)
• polymorphous rash
• cervical lymphadenopathy

Issue 8 127
Issued: December 2018
Expires: December 2020
FEBRILE NEUTROPENIA ● 1/3
Frequent clinical re-assessment of patients is a vital part of effective management of febrile
neutropenia in children

RECOGNITION AND ASSESSMENT

Definition
• Temperature ≥38°C at any time
• Neutrophils ≤0.5 × 109 cells/L

IMMEDIATE TREATMENT
See Figure 1 (see BNFc for dose reduction in renal impairment)

ALL PATIENTS – with central venous access

• Culture both lumens/port-a-cath. Take FBC, group and save, U&E, lactate (blood gas), LFTs, CRP. If
septic also do a coagulation screen (PT and fibrinogen)
• Urinalysis in all children
• CXR only if respiratory signs i.e. increased respiratory rate, auscultatory signs
• Respiratory viral screen if coryzal and/or cough (nasal or throat)
• Do not wait for results, administer antibiotics
• ‘Door to needle time’ must be within 1 hr
• Follow individual trust antibiotic policy or individual patient plan if resistant organisms

No haemodynamic compromise and NOT on chemotherapy block containing IV methotrexate

®
• Start piperacillin with tazobactam (Tazocin ) 90 mg/kg 6-hrly (maximum single dose 4.5 g) administered
over 30 min

No haemodynamic compromise and on chemotherapy block containing IV methotrexate or penicillin

allergic or previous Tazocin® resistant gram negative infection
• Use meropenem 20 mg/kg 8-hrly over 5 min (maximum single dose 1 g)
• If previous documented MRSA infection, add either teicoplanin 10 mg/kg 12-hrly for 3 doses, then 10
mg/kg once daily, OR vancomycin 15 mg/kg 8-hrly given over at least 60 min, maximum 10 mg/min for
doses above 600 mg (maximum initial single dose 700 mg until levels available). Target trough level 10–
15 mg/L
• Pre-dose vancomycin level before 3rd dose, and no post-dose sample required
• Adjust dose as follows dependent on pre-dose concentration (mg/L):
• <10: give 6-hrly and recheck level before dose 4 or 5
• 10–15: continue current dose and recheck level in 3–5 days
• 15–20: reduce dose by 10–20% and recheck level before dose 4 or 5 (unless higher levels advised by
microbiology)
• >20 and <25: extend interval to 12-hrly. Recheck level at 12 hr and give dose without waiting for result
• >25: stop vancomycin and recheck level after 24 hr to see if therapy can be restarted and to determine
interval

Haemodynamic compromise
• Check A, B, C and initiate appropriate resuscitation
• Give sodium chloride 0.9% 20 mL/kg bolus
• Start meropenem 20 mg/kg 8-hrly over 5 min
• Closely monitor urine output; may require HDU/PICU care

LOW RISK PATIENTS

• No central access and
• Neutrophils >0.5 x 109 cells/L and
• Clinically well
• discuss with oncology team/on-call consultant regarding discharge on oral antibiotics

SUBSEQUENT TREATMENT
• Reassess at 24 hr and chase blood cultures
• Positive cultures: discuss patients with positive blood cultures with microbiologist or paediatric
oncology team for advice on appropriate treatment. Where blood cultures positive for yeast in presence
of suspected line infection, remove lines promptly
• Give culture-positive patients at least 7 days treatment intravenously
Issue 8 128
Issued: December 2018
Expires: December 2020
FEBRILE NEUTROPENIA ● 2/3
• Negative cultures: do not switch initial empiric antibiotics in patients with unresponsive fever unless
there is clinical deterioration or a microbiological indication
• If febrile after 48 hr:
• repeat blood cultures and discuss with on-call consultant/paediatric oncology team
• If febrile after 96 hr or clinically unstable between 48 and 96 hr:
• initiate investigations for fungal infection e.g. US abdo/CXR/CT chest
− repeat blood cultures
− add liposomal amphotericin (AmBisome®) 3 mg/kg/day over 30–60 min, give test dose
100 microgram/kg (maximum 1 mg) over 10 min
− if profoundly neutropenic and after discussion with oncology team consider G-CSF 5 microgram/kg
SC once daily

When to discharge
• If clinically well and afebrile for ≥24 hr, and no growth in blood cultures after 48 hr:
• stop antibiotics
• no need for routine inpatient observation after stopping antibiotics

Issue 8 129
Issued: December 2018
Expires: December 2020
FEBRILE NEUTROPENIA ● 3/3
Figure 1: Management of fever in neutropenic/immunocompromised child

Clinical assessment
No • Blood/urine/stool
• Other cultures as Haemodynamic
haemodynamic
appropriate: FBC, group & compromise
compromise
save, PT + fibrinogen,
U&E, LFTs, CRP, lactate
• Do not wait for results,
administer antibiotics

Administer first dose of antibiotic within 1 hr of

presenting with diagnosis of possible neutropenic fever

• Commence piperacillin with Previous • Check A, B, C and initiate

tazobactam (Tazocin®)
90 mg/kg 6-hrly (maximum
single dose 4.5 g)
• If penicillin allergy or
receiving IV methotrexate or
previous Tazocin® resistant
gram negative infection, use
meropenem 20 mg/kg 8-hrly
(maximum single dose 1 g)
• Stop prophylactic antibiotics
apart from co-trimoxazole
documented
MRSA
infection
Add teicoplanin 10 mg/kg
12-hrly or vancomycin
15 mg/kg 8-hrly (maximum
single dose 700 mg) then
according to levels, target
10–15 mg/L
appropriate resuscitation
• Give sodium chloride 0.9%
20 mL/kg bolus
• Commence meropenem
20 mg/kg 8-hrly (maximum
single dose 1 g)
• Inform senior colleague
• Monitor urine output

Cultures positive Reassess

Discuss with consultant
microbiologist or paediatric
oncology team for advice on
appropriate treatment
Repeat blood
cultures
Patient unwell
Initiate investigations for
fungal infection
e.g. USS abdo/CT chest
All cultures negative
at 48 hr
Continued fever at 48 hr
• Continue current antibiotic
• Do not change antibiotic regimen
without discussing with consultant
• Afebrile for ≥24 hr
and well
• Stop antibiotics
Continued fever at 96 hr and discharge
Add AmBisome® 3 mg/kg/day only • ? oral antibiotics if
after discussion with consultant appropriate

Issue 8 130
Issued: December 2018
Expires: December 2020
FEVER IN THE RETURNING TRAVELLER ● 1/4
Most patients presenting have a mild, self-limiting or easily treatable febrile illness BUT it is important to
consider potentially serious imported infections

When to suspect tropical illness

• Fever >37.5°C
• History of travel to tropics/sub-tropics in previous 12 months

POSSIBLE INFECTIONS
Location of travel Disease
Sub-Saharan Africa • Malaria
• Schistosomiasis
• Amoebiasis
• Rickettsioses
• Meningococcal disease
• Viral haemorrhagic fever
Asia • Malaria
• Dengue fever
• Typhoid fever
• Chikungunya
• Emerging viral infections
Middle East • Brucellosis
• Leishmaniasis
South America/Caribbean • Dengue fever
• Coccidioidomycosis
North America • Rocky Mountain spotted
fever
Australia • Q fever
Mainland Europe • Tick-borne encephalitis

Incubation period
<14 days 2−6 weeks >6 weeks
• Malaria • Malaria • Malaria
• Dengue fever • Enteric fever • TB
• Rickettsial infection • Hepatitis A and E • Hepatitis B
• Leptospirosis • Acute schistosomiasis • Visceral leishmaniasis
• Enteric fevers • Leptospirosis • Schistosomiasis
• Diarrhoeal illness • Amoebic liver abscess • Amoebic liver abscess
• Viral respiratory infection • Infectious mononucleosis • Brucellosis
• Yellow fever • Toxoplasmosis • Visceral larva migrans
• Meningococcal and
pneumococcal sepsis
meningitis

FEBRILE SYNDROMES
Fever and hepatitis
• Hepatitis A, B and E
• Leptospirosis
• Infectious mononucleosis
• Amoebiasis

Fever and eosinophilia

• Schistosomiasis
• Ascariasis
• Strongyloidiasis

Fever and lymphadenopathies

• Toxoplasmosis
• EBV
• CMV

Issue 8 131
Issued: December 2018
Expires: December 2020
FEVER IN THE RETURNING TRAVELLER ● 2/4
• HIV
• Brucellosis

Fever and arthropathies

• Chikungunya virus
• Dengue fever
• Pyogenic septic arthritis
• Acute rheumatic fever
• Human parvovirus B19

Fever and diarrhoea

• Shigellosis
• Salmonellosis
• Amoebiasis
• Campylobacter
• Clostridium difficile
• E.coli infection
• Rotavirus

Chronic relapsing and recurrent fever

• Malaria
• Relapsing fever
• Enteric fever
• Brucellosis
• Q fever
• Leptospirosis
• Familial Mediterranean fever

Fever and haemorrhagic manifestations

• Dengue fever
• Yellow fever
• Lassa fever
• Rift Valley fever
• Viral haemorrhagic fevers
• Meningococcal disease

Fever and exanthema

• Maculopapular
• dengue fever
• chikungunya
• measles
• rubella
• enterovirus
• yellow fever
• rickettsial
• Petechial/purpura
• N. meningitides
• rickettsial
• Erythema multiforme
• drug reactions
• Vesicular
• chicken pox
• rickettsial infections
• herpetic
• Erythema nodosum
• TB

Fever and central nervous system disease

• Meningitis
• Enterovirus
• Malaria

Issue 8 132
Issued: December 2018
Expires: December 2020
FEVER IN THE RETURNING TRAVELLER ● 3/4
• Arboviral meningoencephalitis
• Rabies
• Japanese encephalitis virus
• West Nile virus
• TB

Fever and abdominal pain

• Enteric fevers (typhoid and paratyphoid)
• Adenovirus
• Liver abscess

Fever, respiratory symptoms and pneumonia

• Pneumococcal
• Influenza
• RSV
• TB
• Histoplasmosis
• Adenovirus
• Legionellosis
• Q fever
• Diphtheria
• Anthrax

COMMONEST CAUSES OF FEVER IN RETURNING TRAVELLERS

• Diarrhoeal illness
• Malaria
• Dengue
• Enteric fever
• Respiratory infections

TRAVEL HISTORY
• Location and duration of travel
• Reason for travel
• Sources of food and water
• Activities undertaken whilst travelling
• History of insect bites
• Recommended vaccinations received before travelling
• Recommended malaria prophylaxis received and course adherence
• Any illness while abroad and treatment used while travelling (especially antibiotics)

INVESTIGATIONS
• FBC, U&E, LFTs, CRP, ESR and coagulation
• Blood film
• Rapid diagnostic test; has high specificity and sensitivity but gives no information on level of
parasitaemia in malaria
• perform if travel to malaria region within previous 12 months, even if prophylaxis taken
• repeat 3 films 12 hr apart
• Urine microscopy and culture
• Stool microscopy and culture
• Blood culture (important for typhoid fever)
• CXR (pneumonia/TB)

ADDITIONAL INVESTIGATIONS
• If LFTs deranged, hepatitis serology
• PCR for Dengue virus
• Sputum sample for TB
• HIV antibody
• Serum save
• EDTA save for PCR
• LP

Issue 8 133
Issued: December 2018
Expires: December 2020
FEVER IN THE RETURNING TRAVELLER ● 4/4
TREATMENT
• Seriously ill child – manage according to APLS principles, broad spectrum antibiotics and early
discussion with ID team
• Malaria (see Malaria guideline)
• Discuss with local microbiology team and paediatric ID team

INFECTION CONTROL
• Initially manage febrile returning travellers in a side room (specific suspected/confirmed infections may
then require more/less intensive infection control measures)
• Inform laboratory personnel of certain suspected infections
• Consider whether notifiable disease (see Notifiable infectious diseases and food poisoning
guideline)

REMEMBER
• Most patients presenting with fever in the returning traveller have a mild, self-limiting or easily treatable
febrile illness commonly seen in the UK
• Consider disease outbreaks and emerging viral infections
• Consider important non-infectious causes of fever and systemic illness e.g. Kawasaki disease, juvenile
idiopathic arthritis, SLE, leukaemia, lymphoma, haemophagocytic lymphohistiocytosis (see Fever of
unknown origin and Febrile illness guidelines)

Issue 8 134
Issued: December 2018
Expires: December 2020
FEVER OF UNKNOWN ORIGIN ● 1/3
RECOGNITION AND ASSESSMENT
Fever
• Type of thermometer used, site, user (factitious)
• Duration, height
• Pattern:
• intermittent [pyogenic, TB, lymphoma, juvenile idiopathic arthritis (JIA)]
• baseline raised (viral, endocarditis, lymphoma)
• sustained (typhoid)
• days between (malaria, lymphoma)
• weeks between (metabolic, CNS, cyclic neutropenia, hyper-IgD)
• Circumstances when fever (e.g. exercise)
• Appearance
• when fever: well (factitious)
• between fever: ill (serious)
• Response to paracetamol and or NSAID (no response: dysautonomia)

Symptoms
• Red eyes (Kawasaki)
• Nasal discharge (sinusitis)
• Recurrent pharyngitis with ulcers (periodic fever)
• GI: salmonella, intra-abdominal abscess, inflammatory bowel disease (IBD)
• Limb pain (leukaemia, osteomyelitis)

Contact
• Human illness
• Animals

Travel
• Years ago (histoplasmosis)
• Part of country
• Prophylaxis and immunisations
• Contaminated water/food
• Bites (tick: arbovirus, malaria)
• Meat: undercooked (brucella, toxoplasma, hepatitis)
• Pica (visceral larva migrans, toxoplasmosis)

Medical history
• Operations

Drug history
• All, including any non-prescription

Ethnic group
• Sephardic Jew, Armenian, Turkish, Arab (Familial Mediterranean Fever)
• Ashkenazi Jew (familial dysautonomia)

Examination
• Sinuses
• Lymph nodes
• Chest: murmur, crackles
• Abdominal: hepato/spleno-megaly (salmonella, cat scratch, endocarditis, malaria)
• Genito-urinary: girls – pelvic tenderness (child sex abuse – STI)

Skin
• Rash only during fever (JIA)
• No sweat (familial dysautonomia)
• Petechiae (endocarditis, rickettsia)
• Papules (cat scratch)
• Eschar (tularaemia)
• Erythema migrans (Lyme)

Issue 8 135
Issued: December 2018
Expires: December 2020
FEVER OF UNKNOWN ORIGIN ● 2/3
• Malar (SLE)
• Palpable purpura [polyarteritisnodosa (PAN)]
• Erythema nodosum (JIA, SLE, malignancy, IBD, TB)
• Seborrheic (histiocytosis)
• Sparse hair (ectodermal dysplasia)
• Scars (dysautonomia)

Eyes
• Conjunctivitis:
• palpebral (infectious mononucleosis)
• bulbar (Kawasaki)
• phlyctenular (TB)
• Retinopathy (PAN, miliary TB, toxoplasmosis, vasculitis)
• Pupil dilation (hypothalamic or autonomic dysfunction)

Oropharynx
• Red, no exudates (EBV)
• Stomatitis, pharyngitis, adenitis (PFAPA)
• Dental abscess
• Conical teeth (ectodermal dysplasia)
• Smooth tongue (dysautonomia)
• Gum hypertrophy, tooth loss (leukaemia, histiocytosis)

Musculoskeletal
• Tender:
• bone (osteomyelitis, malignancy)
• muscle (trichinella, arbovirus, dermatomyositis, PAN)
• Trapezius (subdiaphragmatic abscess)
• Reflexes
• brisk (hyperthyroid)
• absent (dysautonomia)

Investigations
Initial
• FBC:
• low Hb (malaria, endocarditis, IBD, SLE, TB)
• high platelets (Kawasaki)
• blasts (leukaemia)
• eosinophils (fungal, parasites, neoplastic, allergic, immune deficiency)
• ESR/CRP: normal (factitious, dysautonomia, drug fever)
• LFTs: abnormal (EBV, CMV)
• Blood cultures: several times (endocarditis)
• Urine: pyuria (Kawasaki, intra-abdominal infection, GU, TB)
• Stool culture
• Throat swab
• CXR

Secondary
• IgG, IgA, IgM
• Serology: EBV, CMV, HIV
• Anti-nuclear antibodies
• Sinus CT
• Abdominal ultrasound
• Whole body MRI

Selective
• Echocardiogram
• Bone marrow with culture (leukaemia, histiocytic-haemophagocytosis, TB)
• Serology (syphilis, brucella, toxoplasma)
• Auto-antibodies (rheumatoid arthritis, SLE)

Issue 8 136
Issued: December 2018
Expires: December 2020
FEVER OF UNKNOWN ORIGIN ● 3/3
• IgE (allergy, eosinophilia)
• IgD (periodic fever)
• Gastric aspirate, (induced) sputum (TB)
• Ophthalmologist (uveitis, leukaemia)
• Biopsy (lymph node, liver)

Imaging (as indicated)

• CT/MR chest/abdo (IBD, abscess, lymphadenopathy)
• White cell scan (abscess)
• Bone scan (osteomyelitis)
• PET scan (abscess)

EMPIRICAL TREATMENT
• Critically ill: see Sepsis (including meningococcal) guideline
• TB treatment: discuss with TB team
• Otherwise avoid antibiotics until organism isolated

REFERRAL
• Rheumatology (JIA, connective tissue disorder)
• Gastroenterology (IBD)
• Cardiology (endocarditis/Kawasaki)

Issue 8 137
Issued: December 2018
Expires: December 2020