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

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Related Pathway
Febrile Infant, Inpatient Treatment

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Reducing Lumbar Punctures for Febrile Newborns

Low Risk Criteria 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 visible infections on exam
Blood
WBC ≥ 5,000 and ≤ 15,000
Band to neutrophil ratio < 0.2
(Bands/bands + neutrophils)
Chest X-ray (if obtained)
No infiltrate

NOTE: An abnormal enhanced UA
(WBC ≥ 10/HPF or positive gram stain) is not associated with an increased risk for bacterial meningitis and is no longer included in low risk criteria.

Triage (Critical/Acute)

MD/CRNP/RN Assessment
and Bedside Procedure

IV access
CBC, blood culture
Bedside glucose as needed
Consider HSV and Other Diagnostic Testing
Cath
Enhanced UA, urine culture
LP tray at bedside
History and Physical

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

Perform LP
Antimicrobials
Admit

Infant 29 to 56 Days

Review Low-risk Criteria and UA Results

*HIGH RISK

Perform LP
Antimicrobials
Admit

Abnormal Enhanced or Standard Urinalysis and Meets Low-risk Criteria

No LP needed
Ampicillin and gentamicin

*Infants who fail to
meet any low risk
criteria are considered
HIGH RISK

Needs Admission
for Bronchiolitis

No antimicrobials if meets low-risk criteria
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)
Age	Not ill-appearing and no pleocytosis*	Ill-appearing and/or pleocytosis
0-21 days	Ampicillin Ceftazidime Acyclovir	Vancomycin Cefepime Acyclovir
22-28 days	Ampicillin Ceftazidime	Vancomycin Cefepime
29-56 days	Ampicillin Ceftriaxone	Vancomycin Ceftriaxone

*Not ill-appearing but subsequently found to have pleocytosis:
Give vancomycin in ED.

Additional Considerations: Some patients may have been judged to be well-appearing and given the indicated antibiotics. If such a patient is then found to have a pleocytosis, treat with vancomycin in the ED.
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, August 2019
Authors: R. Scarfone MD; P. Gala MD; A. Murray MD; MK Funari RN; J. Lavelle MD; L. Bell MD; C. Jacobstein, MD

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Evidence

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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.