ED Pathway for Evaluation/Treatment of Febrile Young Infants (0-56 Days Old)
  • Philadelphia Criteria (29-56d)
    Well-appearing
    WBC ≥ 5 k and ≤ 15 k
    Band to neutrophil ratio < 0.2
    (Bands / Bands + neutrophils)
  • Enhanced UA:
    WBC < 10/HPF
    Negative Gram stain
  • CSF:
    WBC < 8/HPF
    Normal glucose, protein
    Negative Gram stain
  • If Obtained:
    CXR clear
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MD/CRNP/RN Assessment
and Bedside Procedure

Ill Infant
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Antimicrobials
Admit
Infant
< 29 Days
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Perform LP
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Antimicrobials
Admit
Infant 29 to 56 Days
No bronchiolitis
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Perform LP
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Review
Philadelphia Criteria
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Low Risk
Not Low Risk
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Assure 24 hr f/u
Discharge
Antimicrobials
Admit
Infant 29 to 56 Days
Clinical bronchiolitis
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Review
Philadelphia Criteria
(without CSF)
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Not Low Risk
Perform LP
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Low Risk
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Needs admission for Bronchiolitis
Able to D/C Consider LP
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No Antibiotics
Admit
Normal Results
Assure 24h f/u
Discharge

Antimicrobial Therapy:
(Meningitic doses are used initially-see ED Febrile Infant Order Set)

0-21 days Ampicillin/Cefotaxime/Acyclovir
22-28 days
Ampicillin/Cefotaxime
29-56 days
Cefotaxime
 
Additional Considerations:
Add Vancomycin Ill Patient
CSF WBC > 8 w/abnormal glucose or protein
Gram positive organism on Gram stain
   
Call ID Gram negative organism on Gram stain
Imipenem and Amikacin
   
HSV
Testing / Treatment

Start Acyclovir for infants ≤ 21 days OR for infants 22 to 40 days with ≥ 1 of the following:
Ill Appearing
Abnormal neurologic status, seizures
Vesicular rash
Hepatitis

Posted: August 2010
Revised: September 2011
Authors: J. Lavelle, MD, M. Mittal, MD, R. Scarfone, MD, D. Potts, RN, L. Bell, MD