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

Goals and Metrics
  • 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 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.
Febrile Young Infant
Review ED Care
All Infants 0-28 Days
All Ill Infants 0-56 Days
Perform LP
Antimicrobials
Admit

Blood, Urine, CSF Cultures NEGATIVE

CSF Profile NORMAL, Gram Stain NEGATIVE

Enhanced UA NORMAL

HSV, CSF, Blood, PCR NEGATIVE, if sent

OR
Enterovirus Meningitis
Interpretable LP

Discharge 24 hours from time of last culture if child looks well

Uninterpretable LP/Bloody Tap

Discharge 36 hours from time of last culture if child looks well

Discharge Planning
Infant 29 to 56 Days
Review Low-risk Criteria and UA Results
*HIGH RISK
  • Perform LP
  • Antimicrobials
  • Admit
*Infants who fail to meet any low-risk criteria are considered HIGH RISK
  • Abnormal Enhanced or Standard Urinalysis and Meets Low-risk Criteria
    • No LP needed
    • Ampicillin and gentamicin
Low Risk with bronchiolitis symptoms
  • Positive Blood Culture
  • Perform LP
  • Consider broadening abx
  • Consider ID consult
  • Ill-appearing
  • Perform LP
  • Consider broadening abx
  • Consider ID consult
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
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: May 2011
Revised: October 2013, February 2014, August 2016, October 2017, September 2018, October 2018, August 2019
Authors: L. Bell, MD; E. Kane MD, MS; J. Lavelle, MD; A. Simon, CRNP; T. Metjian, PharmD