Fever Without a Focus Guidelines

Updated: Sep 01, 2021
  • Author: Saul R Hymes, MD, FAAP; Chief Editor: Russell W Steele, MD  more...
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Guidelines

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). [19, 20]  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.