Inpatient Clinical Pathway for Evaluation/Treatment
of Febrile Infants Less than 56 Days Old
- 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.
All Infants 0-28 Days
All Ill Infants 0-56 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
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
Infant 29 to 56 Days
Review Low-risk Criteria and UA Results
*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
- 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
Antimicrobial Therapy: |
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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. |
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HSV Testing/ Treatment |
Start Acyclovir for ALL infants ≤ 21 days and for infants 22 to 40 days with ≥ 1 of the following: |
Posted: May 2011
Revised: August 2019
Authors: L. Bell, MD; E. Kane MD, MS; J. Lavelle, MD; A. Simon, CRNP; T. Metjian, PharmD
Revised: August 2019
Authors: L. Bell, MD; E. Kane MD, MS; J. Lavelle, MD; A. Simon, CRNP; T. Metjian, PharmD