So let’s break this down by age group and here’s how we will typically manage infants who present with fever given everything we’ve come to learn so far. If an infant is under 28 days and that infant is febrile and well appearing, we’re going to get a urinalysis and a urine culture, we’re going to get a CBC or maybe also a CRP and a procalcitonin depending on your local center and the blood culture and virtually everyone will get a spinal tap.
Occasionally we might not get a spinal tap. If a child clearly has bronchiolitis and we’re afraid that the respiratory stress is so severe it’s hard to tap them but generally we’re going to do our best to get that spinal tap. If there are any abnormal labs, then we’re going to treat them but even if there’s not abnormal labs we’re going to admit them to the hospital and we usually will give antibiotics.
We might make exceptions in a child who clearly has another source of fever such as bronchiolitis and all the labs are completely pristine. If the labs are abnormal or even if they’re normal, most of the time we’ll admit them and we’ll put them on antibiotics which involve either ampicillin and gentamicin or ampicillin and cefotaxime.
The ampicillin is needed to treat group B strep and <i>Listeria</i>, although many people are thinking <i>Listeria</i> is less common than it used to be it still does sometimes come around. Remember, ceftriaxone is not indicated in children under 28 days of age because of concerns of kernicterus. We will now wash them on antibiotics for a 24 to 36-hour period.
Gone are the days of the 48-hour rule out, we’ve now really limited this to 24 or 36 hours and if all cultures are negative we can send them home. What about a child between 4 weeks and 8 weeks of age? In these children in this age range of 29 to 60 days we see a febrile infant, we’re going to get the urine, the urinalysis and those blood tests.
Many centers are moving away from doing a spinal tap on all of these patients, although it’s a judgment call. Certainly if the child if sick appearing, I would get a spinal tap but I might avoid it in a very well-appearing child especially one with bronchiolitis or some other cause of fever.
If the urinalysis and the preliminary studies of blood, the CBC, the CRP or the procalcitonin are abnormal, then we’re going to worry but if they are not abnormal we can discharge the patient home with close followup.
These patients who are well appearing with fever, who have preliminary labs that are normal do not necessarily need to come into the hospital but if the labs are abnormal or you’re worried about the child or you don’t trust that they’ll follow up we will often admit them.
If we’re admitting them, the decision about the LP as a challenging one, I certainly would not do antibiotics unless I done the LP because it’s a nightmare when you’ve already given the antibiotics and then you decide you might need an LP because that LP sterilizes within an hour of giving the antibiotics.
So we really want to avoid giving antibiotics in a patient who hasn’t yet gotten an LP. If the urinalysis is the only positive lab and the LP is normal, we might consider discharge on oral antibiotics especially if there’s a low rate of drug resistance in urinary tract infection organisms in your community.
That’s a style decision and I would leave that up to each individual practitioner and each individual patient. Now, if only the CBC is abnormal, you could consider discharge on oral antibiotics and closely watching at home and then telling patients “Well, you can stop the antibiotics.”
This is an alternative that some people are practicing. It’s not common. If a child is admitted, we generally again watch for 24 to 36 hours and discharge if all the cultures are negative. Let’s finally consider those children who are over 61 days and up.
Here’s a febrile infant, we’re worried. We’re really outside the realm of bacteremia and we’re certainly outside the realm of meningitis, the only thing we might need to worry about is urinary tract infection in a child who has no other source of fever. So you’ll get a UA, if it’s normal they can go home, if it’s abnormal they can still go home.
We can treat most urinary tract infections with oral antibiotics. Of course if the child is severe, then we’ll keep them in-house but if a child is well appearing with the fever at this age they’re usually okay to go home. So that’s a brief summary as best I can do of how we manage febrile infants who present to the emergency room. Thanks for your attention.
