Neonatal Fever (29 - 60 days)



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Neonatal Fever (29 - 60 days)

Well appearing?

All urine specimens should be collected by straight catheterization or suprapubic aspiration. Please document method of collection.

Signs/symptoms of clinical bronchiolitis?

HOSPITALIZE

High risk criteria?

Inclusion Criteria
  • Fever > 38.0 C (100.4 F) at home of by provider
Exclusion Criteria
  • Toxic or moderately ill

If HSV risk factors** are present, add HSV serum PCR (may send from floor).

Add lumbar puncture

CSF:

  • culture and Gram stain,
  • protein and glucose,
  • cell count,
  • HSV PCR (CSF), enterovirus PCR in season (June-October)

Start Empiric Antimicrobials

  1. Cefotaxime or ceftriaxone
  2. Acyclovir only if HSV risk factors** are present

Antimicrobial Dosing

cefTRIAXone IV

100 mg/kg/DOSE every 24 hours

cefotaxime IV (alternative to ceftriaxone)

50 mg/kg/DOSE every 8 hours

acyclovir IV

20 mg/kg/DOSE every 8 hours

Please consult Pediatric ID if:

  • CSF abnormalities
  • Positive blood and/or CSF cultures
  • Febrile at 48 hours in spite of treatment

Consider discharge to home and further outpatient management after 36 hours if:

  • Bacterial cultures are negative
  • CSF HSV PCR is negative
  • Good follow-up for serum HSV PCR (if pending) is assured

If you have questions about any of the clinical pathways or about the process of creating a clinical pathway please contact the Clincal Pathway Oversight Committee at CPOC@montefiore.org.

Disclaimer: Clinical pathways are intended as a resource to guide diagnosis, treatment and management in order to improve quality of care and promote better patient outcomes. They are based on available medical evidence at the time of development; the date on the pathway indicates the most recent update. Pathways are not intended to provide medical advice or consultation regarding the care of any individual patient, and should not replace or supersede a practitioner’s professional opinion or clinical judgment. Because medical knowledge is constantly evolving, and accepting the possibility of error, The Children’s Hospital at Montefiore does not warrant or represent that pathways are complete or accurate. Neither the Hospital nor the individuals involved in the development or publication of the pathways is responsible for results or outcomes related to their use.

If no high risk criteria* are present, consider DISCHARGE TO HOME. If hospitalization is indicated, observe without antibiotics. Consider discharge to home and further outpatient management if bacterial cultures are negative after 24 hours.

**HSV RISK FACTORS

  • First clinical episode of maternal HSV in 4 weeks prior to delivery
  • History of mother being on suppressive ACV/valacyclovir
  • Exposure to someone with cold sore
  • Circumcision with Metzitzah B'Peh
  • Skin lesion suspicious for HSV
  • Seizures
  • Elevated ALT
  • CSF pleocytosis

  • Consider UA (with micro) and urine culture
  • Proceed to Clinical Bronchiolitis Pathway
  • If UA is positive, resume Fever in Infants Pathway

Corresponding Epic Order Set:

  • IP Peds Fever in Baby 29-56 days old

TOXIC OR MODERATELY ILL:

  • Full sepsis work-up
  • Start empiric anti-microbials
  • Hospitalize
  • If LP is deferred due to clinical instability, begin empiric antimicrobials and perform LP as soon as patient is stabilized

Collect:

  • Blood: CBC w/diff, BCx, LFTs, glucose, CRP, HSV serum PCR (may send from floor)
  • Urine: UA w/micro, Ucx
  • RSV/flu only if respiratory symptoms present
  • CXR only if respiratory symptoms present
  • Stool studies if diarrhea present
  • HSV DFA or PCR if skin lesions present

Criteria for Outpatient Management (all must apply):

  • Physician identified to assume outpatient follow-up at 24 hours
  • Caregiver with good observation skills
  • Telephone in home or a cell phone
  • Access to PMD or ED within 30 minutes

*HIGH RISK CRITERIA

  • WBC <5,000 or >15,000
  • CRP >2
  • AST>45, AST>75
  • CXR abnl (if obtained)

OR

  • recent antibiotic therapy

OR

  • history of prematurity




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