Febrile Infant (29-60 days of age)



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Febrile Infant (29-60 days of age)

High or low risk for bacterial infection?

Complete discharge checklist

Clinical decision to administer antibiotics?

HSV Risk Assessment

If any “Yes”, proceed to high risk recommendations.

  • Maternal history of HSV (prior disease or active lesions)?
  • History of seizures or seizures during the evaluation
  • Vesicles on skin exam (including scalp)
  • CSF with pleocytosis for age?

Consider discharge with 24 hour follow-up

High or low risk for HSV?

Inpatient care

Last edited 7/2020 (TN)

Inclusion Criteria
  • Age 29-60 days
  • Fever >38C (>100.4F) as measured at home or in hospital
Exclusion Criteria
  • <29d of age or >60d of age
  • Ill-appearing
  • Co-morbid conditions (immunosuppression, VP shunt present, central venous catheter)

Is patient well-appearing?

Admit for observation off antibotics

Obtain:

  • UA (cath specimen) / Urine culture
  • CBC w/ diff
  • Blood culture
  • Procalcitonin
  • Respiratory symptoms: consider RSV/influenza, CXR 2-view, respiratory pathogen panel PCR
  • Diarrhea: consider stool culture, O&P

References:

Project REVISE


Obtain:

  • HSV PCR of conjunctivae, nasopharynx, mouth, and rectum
  • (OK to use same swab for all samples-- obtain in same order as above starting with conjunctivae and ending with rectum)
  • HSV 1+2 PCR CSF
  • HSV 1+2 PCR Plasma
  • Comprehensive Metabolic Panel (to include LFTs)
  • Administer acyclovir 20mg/kg IV (in addition to antibiotics)
  • Monitor patient on acyclovir pending HSV PCR and culture results
  • Discontinue acyclovir when PCR negative

Complete full sepsis evaluation and management

Bacterial Infection Checklist:

If any “YES” proceed to High Risk for Bacterial Infection recommendations

  • Born at less than 37 weeks gestation?
  • History of prior hospitalization?
  • Prolonged newborn nursery course?
  • Is WBC less than 5,000/cc or greater than 15,000/cc?
  • Is UA positive for nitrites, leuk esterase, or WBC > 5/HPF?
  • Are bands > 1500/cc?
  • Is PCT elevated? (CRP elevations considered less worrisome if clinical picture consistent with viral illness)
  • Does the child have a chronic illness?
  • Received antibiotics prior to this visit?
  • History of unexplained hyperbilirubinemia?
  • Signs of a skin infection to suggest cellulitis?
  • Elevated CSF RBCs not from a traumatic tap?

Discharge Disposition Checklist

If any “No”, admit the patient:

  • Are the parents comfortable with monitoring their child at home?
  • Do the parents have reliable means of receiving communication from the hospital/ED?
  • Can bacterial culture results be followed daily by the hospital/ED?
  • Can the patient follow-up with their PCP in 24 hours?
  • Has the pediatric hospitalist been consulted?

  • Perform lumbar puncture (CSF culture & gram stain, cell count, protein, glucose) save extra/remainder on ice)
  • (Consider treating without LP if UA strongly suggestive of UTI and no clinical suspicion of meningitis)
  • Administer antibiotics:
  •     Ceftriaxone 50mg/kg IV
  •     Add vancomycin 10mg/kg IV for patients at risk for Staph aureus infection or with central line
  •     If hyperbilirubinemia, cefotaxime 50mg/kg IV may be an alternative to ceftriaxone. If unavailable, consider ceftazidime 30mg/kg IV
  • Admit patient




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