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

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Goals and Metrics

Febrile Young Infant Qlkiview 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

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 Urinalysis
and/or Culture
May use Febrile UTI Clinical Pathway as resource

Negative Culture, well-appearing disposition
Discharge Planning

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

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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.