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

Goals and Metrics
Related Pathway
Febrile Infant, Inpatient Treatment
Quality Story
Reducing Lumbar Punctures for Febrile Newborns
Febrile Young Infant
  • 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
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; T. Metjian, PharmD