Febrile Neonate (7-28 days of age)

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Febrile Neonate (7-28 days of age)

High or low risk for HSV?

Inpatient care

Clinical decision to administer antibiotics?

High or Low risk for bacterial infection?

Plan for admission for observation off antibiotics

This option should be reserved for an extremely well appearing infant nearing 1 month of life with a reassuring history, exam, and laboratory work-up. Note that invasive disease including meningitis and HSV can present with only fever, particularly in younger infants.

Though changes are being discussed, national published guidelines continue to conservatively recommend LP and antibiotics in all infants under 1 month of age.

Inclusion Criteria
  • Age 7-28 days
  • Fever > 38C (>100.4F) as measured at home or in hospital
Exclusion Criteria
  • <7d of age
  • Ill-appearing
  • Known immunodeficiency or cancer
  • Central venous catheter or VP shunt
  • Patient presenting with seizure
  • Perform lumbar puncture (CSF culture & gram stain, cell count, protein, glucose) save extra/remainder on ice)
  • Administer antibiotics (ampicillin 100mg/kg IV and cefotaxime 50mg/kg IV)
  • Change to ampicillin plus gentamicin 4mg/kg IV if no CSF pleocytosis (<20 WBC)
  • Admit patient and refer to relevant order set

HSV Risk Assessment

If any 'Yes', proceed to high-risk HSV recommendations:

  • Maternal history of HSV (prior disease, active lesions)
  • Postnatal HSV contact
  • History of seizures or seizures during evaluation
  • Severe illness or lethargy
  • Hypothermia <36C
  • Vesicles on skin exam (including scalp)
  • Hepatosplenomegaly
  • Conjunctivitis
  • CSF pleocytosis >20WBC
  • Elevated CSF RBCs (not traumatic tap)
  • Transaminitis
  • Thrombocytopenia

Last updated 7/20/20 (TN)


Project REVISE (Reducing Variability in Infant Sepsis Evaluation)

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 either the CRP or PCT elevated?
  • 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?

Is the patient well-appearing?


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


  • HSV PCR and culture from any vesicles
  • HSV PCR from eye, mouth, rectum
  • HSV1+2 PCR from plasma
  • HSV1+2 PCR from CSF
  • Comprehensive metabolic panel (including liver function)
  • Administer 20mg/kg IV acyclovir
  • Monitor patient pending PCR and culture results
  • Discontinue acyclovir when HSV PCR negative

Complete full sepsis evaluation & management

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