Febrile Infant Clinical Pathway — Emergency | Children's Hospital of Philadelphia

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Goals and Metrics

Related Pathway
Inpatient Febrile Young
Infant Pathway

Quality Story
Reducing Lumbar Punctures for Febrile Newborns

Febrile Young Infant

Low Risk for Bacterial Meningitis:
29-56 days old
Full-term (≥37 weeks gestation)
No prolonged NICU stay
No chronic medical problems
No systemic antibiotics within 72 hours
Well-appearing and easily consolable
No infections on exam
Blood:
WBC ≥ 5,000 and ≤ 15,000
Band to neutrophil ratio < 0.2
(Bands/bands + neutrophils)
Enhanced UA:
WBC < 10 /HPF
Negative Gram stain
Chest x-ray (if obtained):
No infiltrate

Triage (Critical/Acute)

MD/CRNP/RN Assessment
and Bedside Procedure

IV access
CBC, blood culture
Bedside glucose as needed
Consider need for blood HSV PCR
Cath
Enhanced UA, urine culture
LP tray at bedside
H & P
Additional Diagnostic Tests
Consider need for HSV testing

All Infants 0-28 Days
All Ill Infants 0-56 Days

Perform LP
Antimicrobials
Admit

Infant 29 to 56 Days
with or without Bronchiolitis

Review Low Risk Criteria, including CBC and enhanced UA (without CSF)

*HIGH RISK

Perform LP
Antimicrobials
Admit

Needs Admission
for Bronchiolitis

No antimicrobials
Admit

LOW RISK

No antimicrobials
Discharge
Assure NP follow-up call

Rationale for antibiotic choices

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	Ceftriaxone

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 CFS Gram stain Meropenem and Amikacin

HSV Testing/ Treatment	Start Acyclovir for ALL infants ≤ 21 days and for infants 22 to 40 days with ≥ 1 of the following: Ill Appearing Abnormal neurologic status, seizures Vesicular rash Hepatitis Mom known to have primary HSV infection at delivery

Posted: August 2010
Revised: September 2011, April 2014, October 2014, November 2015, October 2017
Authors: R. Scarfone MD; R. Gala MD; A. Murray MD; MK Funari RN; J. Lavelle MD; L. Bell MD

Learn More

LearningLink Module (for CHOP employees) +

Journals & Articles

Unpredictability of Serious Bacterial Illness in Febrile Infants From Birth to 1 Month of Age +
A. Huppler, J. Eickhoff, E. Wald. Performance of Low-Risk Criteria in the Evaluation of Young Infants With Fever: Review of the Literature PEDIATRICS Vol. 125 No. 2 February 1, 2010 pp. 228-233 +
C. Byington, C. Reynolds, K, Korgenski, et al. Costs and infant outcomes after implementation of a care process model for febrile infants. Pediatrics. 2012 Jul;130(1):e16-24. pp. 228-233 +

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.