Guidelines Summary

Clinical practice guidelines on the evaluation and management of febrile infants were published in August 2021 by the American Academy of Pediatrics (AAP).^{[11, 12]}The guidelines cover the assessment and treatment of well-appearing term infants aged 8-60 days who have a fever of at least 100.4°F (38°C).

Infants Aged 8-21 Days

Urinalysis, blood culture, and analysis of cerebrospinal fluid (CSF) are strongly recommended for infants in this age group. Parenteral antimicrobial therapy and active monitoring by nurses and hospital staff with experience in neonatal care are also strongly recommended. Infants with positive results of urine, blood, or CSF testing for bacterial pathogens should receive targeted antimicrobial therapy. Parenteral antibiotics can be discontinued and patients can be discharged when culture results have been negative for 24-36 hours and the infant appears clinically well or is improving.

Infants Aged 22-28 Days

Urinalysis, blood culture, and assessment of inflammatory markers are strongly recommended for infants in this age group. If more than one inflammatory marker level is abnormal, CSF analysis and bacterial culture are recommended. When CSF analysis has not been performed or the results are uninterpretable, the infant should be hospitalized. Antimicrobial agents can be discontinued and patients can be discharged when culture results have been negative for 24-36 hours, the infant appears clinically well or is improving, and no other infection requiring treatment is present.

Infants may be managed at home if they have negative CSF analysis and urinalysis results and no abnormal inflammatory marker levels. Infants who will be treated at home should receive parenteral antimicrobial therapy. In addition, home care should involve verbal and written instructions for caregivers, plans for re-evaluation in 24 hours, and plans for access to emergency care if the patient’s clinical status changes.

Infants Aged 29-60 Days

Urinalysis, blood culture, and assessment of inflammatory markers are recommended for infants in this age group. If all inflammatory marker levels are normal, CSF analysis and culture are not necessary. However, CSF testing may be performed if any inflammatory marker level is abnormal. If CSF analysis suggests bacterial meningitis, parenteral antimicrobial therapy is strongly recommended. Antimicrobial therapy is not required for patients with normal CSF analysis results, negative urinalysis results, and normal results of testing for inflammatory markers.

Medication

Edwards MS, Nizet V, Baker CJ. Group B streptococcal infections. Remington JS, Klein JO, Wilson CB, Baker CJ, eds. Infectious Diseases of the Fetus and Newborn Infant. 6th ed. Philadelphia, Pa: Elsevier Saunders; 2006. 403.
Byington CL, Enriquez FR, Hoff C, et al. Serious bacterial infections in febrile infants 1 to 90 days old with and without viral infections. Pediatrics. 2004 Jun. 113(6):1662-6. [QxMD MEDLINE Link].
Agency for Healthcare Research and Quality. Diagnosis and Management of Febrile Infants (0-3 months) Executive Summary. Agency for Healthcare Research and Quality. March 2012. Available at http://www.effectivehealthcare.ahrq.gov/reports/final.cfm.
Teele DW, Pelton SI, Grant MJ, et al. Bacteremia in febrile children under 2 years of age: results of cultures of blood of 600 consecutive febrile children seen in a "walk-in" clinic. J Pediatr. 1975 Aug. 87(2):227-30. [QxMD MEDLINE Link].
Herz AM, Greenhow TL, Alcantara J, et al. Changing epidemiology of outpatient bacteremia in 3- to 36-month-old children after the introduction of the heptavalent-conjugated pneumococcal vaccine. Pediatr Infect Dis J. 2006 Apr. 25(4):293-300. [QxMD MEDLINE Link].
Baraff LJ, Bass JW, Fleisher GR, et al. Practice guideline for the management of infants and children 0 to 36 months of age with fever without source. Agency for Health Care Policy and Research. Ann Emerg Med. 1993 Jul. 22(7):1198-210. [QxMD MEDLINE Link].
Wilkinson M, Bulloch B, Smith M. Prevalence of occult bacteremia in children aged 3 to 36 months presenting to the emergency department with fever in the postpneumococcal conjugate vaccine era. Acad Emerg Med. 2009. 16:220-5. [QxMD MEDLINE Link].
Sard B, Bailey MC, Vinci R. An analysis of pediatric blood cultures in the postpneumococcal conjugate vaccine era in a community hospital emergency department. Pediatr Emerg Care. May 2006. 22:295-300. [QxMD MEDLINE Link].
Ahronheim SR, McGillivray D, Barbic S, Barbic D, Klam S, Brisebois P, et al. Expectant parents' understanding of the implications and management of Fever in the neonate. PLoS One. 2015. 10(4):e0120959. [QxMD MEDLINE Link]. [Full Text].
Cruz AT, Mahajan P, Bonsu BK, Bennett JE, Levine DA, Alpern ER, et al. Accuracy of Complete Blood Cell Counts to Identify Febrile Infants 60 Days or Younger With Invasive Bacterial Infections. JAMA Pediatr. 2017 Sep 11. e172927. [QxMD MEDLINE Link].
[Guideline] Pantell RH, Roberts KB, Adams WG, et al. Evaluation and management of well-appearing febrile infants 8 to 60 days old. Pediatrics. 2021 Aug. 148 (2):[QxMD MEDLINE Link]. [Full Text].
Basco WT Jr. The febrile infant: new AAP guidance for the first 2 months of life. Medscape News & Perspective. 2021 Jul 19. Available at https://www.medscape.com/viewarticle/954462.
Bonsu BK, Harper MB. Leukocyte counts in urine reflect the risk of concomitant sepsis in bacteriuric infants: a retrospective cohort study. BMC Pediatr. 2007 Jun 13. 7:24. [QxMD MEDLINE Link]. [Full Text].
Tzimenatos L, Mahajan P, Dayan PS, Vitale M, Linakis JG, Blumberg S, et al. Accuracy of the Urinalysis for Urinary Tract Infections in Febrile Infants 60 Days and Younger. Pediatrics. 2018 Feb. 141 (2):[QxMD MEDLINE Link].
Jaskiewicz JA, McCarthy CA, Richardson AC, et al. Febrile infants at low risk for serious bacterial infection--an appraisal of the Rochester criteria and implications for management. Febrile Infant Collaborative Study Group. Pediatrics. 1994 Sep. 94(3):390-6. [QxMD MEDLINE Link].
Bachur RG, Harper MB. Predictive model for serious bacterial infections among infants younger than 3 months of age. Pediatrics. 2001 Aug. 108(2):311-6. [QxMD MEDLINE Link].
Meehan WP 3rd, Bachur RG. Predictors of cerebrospinal fluid pleocytosis in febrile infants aged 0 to 90 days. Pediatr Emerg Care. 2008 May. 24(5):287-93. [QxMD MEDLINE Link].
Kuppermann N, Fleisher GR, Jaffe DM. Predictors of occult pneumococcal bacteremia in young febrile children. Ann Emerg Med. 1998 Jun. 31(6):679-87. [QxMD MEDLINE Link].
Hoberman A, Wald ER, Reynolds EA, Penchansky L, Charron M. Is urine culture necessary to rule out urinary tract infection in young febrile children?. Pediatr Infect Dis J. 1996 Apr. 15(4):304-9. [QxMD MEDLINE Link].
Bleeker SE, Derksen-Lubsen G, Grobbee DE, Donders AR, Moons KG, Moll HA. Validating and updating a prediction rule for serious bacterial infection in patients with fever without source. Acta Paediatr. 2007 Jan. 96(1):100-4. [QxMD MEDLINE Link].
Isaacman DJ, Shults J, Gross TK, Davis PH, Harper M. Predictors of bacteremia in febrile children 3 to 36 months of age. Pediatrics. 2000 Nov. 106(5):977-82. [QxMD MEDLINE Link].
Lacour AG, Zamora SA, Gervaix A. A score identifying serious bacterial infections in children with fever without source. Pediatr Infect Dis J. 2008 Jul. 27(7):654-6. [QxMD MEDLINE Link].
Baraff LJ. Management of infants and young children with fever without source. Pediatr Ann. 2008 Oct. 37(10):673-9. [QxMD MEDLINE Link].
Hay AD, Costelloe C, Redmond NM, et al. Paracetamol plus ibuprofen for the treatment of fever in children (PITCH): randomised controlled trial. BMJ. 2008 Sep 2. 337:a1302. [QxMD MEDLINE Link]. [Full Text].
Harper MB, Bachur R, Fleisher GR. Effect of antibiotic therapy on the outcome of outpatients with unsuspected bacteremia. Pediatr Infect Dis J. 1995 Sep. 14(9):760-7. [QxMD MEDLINE Link].
Shaikh N, Mattoo TK, Keren R, Ivanova A, Cui G, Moxey-Mims M, et al. Early Antibiotic Treatment for Pediatric Febrile Urinary Tract Infection and Renal Scarring. JAMA Pediatr. 2016 Sep 1. 170 (9):848-54. [QxMD MEDLINE Link].
Garcia J. Febrile UTI: Early Treatment Lowers Risk for Renal Scarring. Medscape Medical News. Available at http://www.medscape.com/viewarticle/866819. July 29, 2016; Accessed: November 1, 2016.

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