Fever without a source (2 mo - 36 months)



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Fever without a source (2 mo - 36 months)

Consider fever of unknown origin pathway

Complete Blood Count, Serum
Blood Culture (Aerobic and Anaerobic), Serum
Urinalysis with micro, Urine
Urine Culture, Urine
X-ray Chest, 1 view

Discharge criteria

  • Reassuring vital signs
  • Tolerating PO
  • Well-appearing
  • No social/family concerns
  • Reliable follow up in 24 hours
  • Parents comfortable and understand discharge plan
  • Provider comfortable with outpatient therapy

Consider UTI and pneumonia pathways

Consider Kawasaki pathway

Discharge with PMD follow up within 24 hours

60 - 90 days old?

Positive CSF findings?

Contraindications to ibuprofen

  • Allergy or hypersensitivity
  • G6PD
  • Renal impairment
  • Severe hypovolemia
  • Bleeding or coagulation disorder
  • Gastritis or PUD
  • Long bone fracture

Choose the correct disposition depending on patient status

Admit to Floor
Admit to ICU
Ceftriaxone injection

Fever > 38.0 C (100.4 F) daily for 5 days?

Culture & Gram Stain, CSF
Glucose, CSF
Protein Total, CSF
Cell Count and Differential, CSF
Ceftriaxone injection
Enterovirus PCR, CSF
Meningitis/encephalitis PCR panel, CSF

Fever > 38.3 C (101 F) daily for 7 days?

Immunization incomplete (<2 doses of PCV and HIB)

Tmax >=39 C (102.2 F), petechial rash, or ill appearing with UTI or diarrhea?

Serum WBC < 5k OR >15k OR bands < 1.5k mm3?

Meets discharge critiera?

Complete Blood Count, Serum
Blood Culture (Aerobic and Anaerobic), Serum
Inclusion Criteria
  • Fever > 38.0 C (100.4 F) x1 rectal or core temperature at home, clinic or ED
Exclusion Criteria
  • Immunosuppressed, cancer
  • Central venous catheter
  • Ventriculoperitoneal shuts
  • Solid organ transplant
  • Complex medical issues

Toxic appearing?

Consider pediatric consult

Recognizable source of fever?

Workup and treat source appropriately

Tmax >= 41 C (106 F)?

Risk of SBI are low (besides UTI), but still present in this age group.

Contraindications to acetaminophen

  • Allergy or hypersensitivity
  • Hepatic impairment
  • Severe hypovolemia
  • PKU or other liver disease
  • Chronic malnutrition

Contraindications to PO challenge

  • Urgent or potential need for surgery
  • Unstable respiratory status
  • History of aspiration or risk from PO feeds
  • Recent mid-face or neck trauma

Complete Blood Count, Serum
Complete Metabolic Panel, Serum
Blood Culture (Aerobic and Anaerobic), Serum
Urinalysis with micro, Urine
Urine Culture, Urine
X-ray Chest, 2 view
Gastroenteritis PCR, Stool
Ceftriaxone injection
ISTAT Venous Blood Gas and Lactate, Serum
Admit to ICU
Vancomycin injection
Culture & Gram Stain, CSF
Glucose, CSF
Protein Total, CSF
Cell Count and Differential, CSF



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