Approach Considerations
The clinical management of infants and toddlers with fever is based on their age groups.
Neonates and young infants should be hospitalized with intravenous antibiotics pending results of laboratory tests and cultures.
For the most part, management should be individualized based on risk factors, clinical appearance, and clinical judgment. Ill-appearing children with poor capillary refill and children who have clinical signs and symptoms suggestive of meningitis need to be managed in hospital and perhaps in the critical care setting. Children with focal infections such as sinusitis and pneumonia need to be managed with appropriate antimicrobial therapy.
For any well-appearing febrile infant considered at higher risk for invasive bacterial infection on the basis of screening tests, the American Academy of Pediatrics recommends a 24- to 36-hour rule-out period with empiric antimicrobial treatment and active monitoring in the hospital. Presumptive treatment can be discontinued if bacterial cultures are sterile after 24-36 hours of incubation. [11, 12]
With the widespread use of pneumococcal vaccine in young children, the incidence of occult bacteremia in febrile children aged 3 months to 3 years has fallen from 4.6% to less than 1%. [5, 23] As such, the evaluation has become more extensive to prevent overtreatment. In the absence of focal findings, any child in the target age group who appears ill or has excessive fever, vomiting, or tachypnea with retractions should be evaluated further.
Parents and medical professionals who want to supplement physical measures with medication in order to maximize the time that children spend without fever should use ibuprofen first and weigh the use of paracetamol plus ibuprofen over 24 hours. [24]
Acetaminophen IV is approved by the FDA for use to treat fever for all aged children, including premature neonates, neonates, and infants.
Fever Management in Neonates and Young Infants
All febrile infants aged 28-60 days, after having a sepsis evaluation, should be hospitalized and empirically started on intravenous antibiotics pending culture results (see Workup). The antibiotic spectrum of coverage must include both community-acquired pathogens (eg, Streptococcus pneumoniae, Haemophilusinfluenzae, Moraxella catarrhalis, Neisseria meningitidis, late-onset group B Streptococcus [GBS], Staphylococcus aureus), perinatally acquired organisms (eg, early onset GBS, Escherichia coli, and other gram-negative organisms and Listeria monocytogenes), or hospital-acquired organisms in the neonate or infant who was recently hospitalized (eg, enteric gram-negative organisms, S aureus).
Empiric antibiotics
Ampicillin and gentamicin, or ampicillin and cefotaxime for the neonate, covers GBS, E coli, Listeria, and most S pneumoniae and N meningitides. For infants aged 1-2 months, recommended empiric coverage includes ampicillin, cefotaxime, and vancomycin to provide adequate coverage for community-acquired pathogens. All antibiotic dosages should be adequate to treat meningitis. For infants older than 2 months, vancomycin and cefotaxime are the empiric antibiotic choices. Vancomycin is especially important if the patient has evidence of soft-tissue infection, given the increasing prevalence of methicillin-resistant S aureus (MRSA), or a cerebrospinal fluid (CSF) profile consistent with bacterial meningitis to cover for antibiotic-resistant S pneumoniae.
Well-appearing and relatively well-appearing infants
Relatively well-appearing febrile infants younger than 28 days who are diagnosed with a viral respiratory illness should have a septic workup that includes cultures of blood, urine, and CSF. These infants should receive empiric antibacterial therapy in hospital until culture results are known.
Infants older than 28 days who look well and whose history, physical examination, and laboratory evaluation findings classify them as low risk can be treated as outpatients with ceftriaxone (50 mg/kg in a single intramuscular dose), as long as 24-hour follow-up can be ensured.
Infants older than 28 days who are diagnosed with bronchiolitis or influenza and are relatively well-appearing should undergo a limited laboratory evaluation, including complete blood cell (CBC) count with differential, blood culture, urinalysis, and urine culture. If the CBC count and urinalysis findings are benign, these patients can be initially managed without antibacterial therapy.
Ill-appearing neonates
Acyclovir (60 mg/kg/d divided every 8 h) is recommended for febrile neonates who appear ill, have mucocutaneous vesicles, experience seizures, or have a CSF pleocytosis. [17] In addition, viral cultures and direct fluorescent antigen detection should be performed on skin vesicles and conjunctival, nasopharyngeal, and rectal mucous membranes. CSF should be assessed for herpes simplex virus (HSV) and undergo polymerase chain reaction (PCR) and viral culture.
Fever Management in Children Aged 3 Months to 3 Years
Empiric antimicrobial therapy in non-toxic children aged 3 months to 3 years is not recommended. For those requiring hospitalization, antimicrobial therapy must provide coverage against the suspected pathogens and must achieve high and sustained serum concentrations. [25] In this setting, a single intramuscular (IM) dose of ceftriaxone has been shown to prevent sustained bacteremia in children whose initial blood culture has yielded Streptococcus pneumoniae.
In vitro, ceftriaxone is also effective against most strains of Escherichia coli, thus supporting the empiric use of this agent until bacterial culture results are known (see Workup). Children at risk for Staphylococcus aureus infections should receive clindamycin as well. Limited data are available regarding the use of alternative agents.
A retrospective study by Shaikh et al that included 482 children younger than 6 years old with a first or second UTI found that renal scarring was associated with a delay in the initiation of antimicrobial therapy. 35 children (7.2%) developed new renal scaring and the median duration of fever before initiation of antibiotic therapy in the group with renal scaring was 72 hours compared to 48 hours in children with no renal scarring. [26, 27]
