Emergency Department Clinical Pathway for Evaluation/Treatment of Febrile Infants Less than 56 Days Old

  • 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.
MD/CRNP/RN Assessment
and Bedside Procedure

All Infants 0-28 Days
All Ill Infants 0-56 Days
Infant 29 to 56 Days
  • Obtain CBC, enhanced UA, blood and Urine Cultures for all
  • Review Low-risk Criteria and UA Results
*HIGH RISK
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
  • Antimicrobial Therapy:
    (Meningitic doses are used initially — see ED Febrile Infant Order Set)
  • 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
  • Rationale for antibiotic choices
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
When to test for and empirically treat (with acyclovir) for HSV
HSV
Testing/

Treatment
  • Patients to be tested for HSV
  • All ≤ 21 days old and those 22-56 days old with any of the following:
  • Pleocytosis or RBCs in CSF
  • Ill-appearance
  • Abnormal neurologic status, seizure
  • Vesicular rash
  • Hepatitis
  • Mom known to have primary HSV infection at delivery
  • HSV testing recommendations
  • Consider HSV and other Diagnostic Testing
Posted: August 2010
Revised: September 2011, April 2014, October 2014, November 2015, October 2017, August 2019, July 2021
Authors: R. Scarfone MD; P. Gala MD; A. Murray MD; MK Funari RN; J. Lavelle MD; L. Bell MD; C. Jacobstein, MD; T. Metjian, PharmD