Febrile Infant

Objectives:

1. Identify key history components relevant to the management of febrile infants
2. Identify key physical exam findings important to the management of febrile infants
3. Review low and high-risk criteria for the management of febrile infants
4. Review helpful algorithms for management of febrile infants in the ED and inpatient settings

Articles:

• The recently published, long awaited 2021 AAP Febrile Infant Guidelines!! (8-60 days old)
• Management and Outcomes of Care of Fever in Early Infancy, Robert Pantell et al.
• Febrile Infant Update, Kate Dorney and Richard Bachur
• Risk of Meningitis in Infants Aged 29 to 90 Days with Urinary Tract Infection: A Systematic Review and Meta-Analysis. Nugent J et al. This paper supports avoiding lumbar puncture in otherwise low-risk, well-appearing febrile young infants 29 to 90 days of age with UTIs
• UpToDate: Febrile Infant (younger than 90 days): Management

Additional Resources:

• CHOP Algorithms. Here is the ED Algorithm and the Inpatient Algorithm These include helpful links to other articles explaining each step of the algorithm
• NEJM Lumbar Puncture video as well as urethral catheterization for boys and for girls

Self-Assessment:

1. After completing a full rule-out sepsis work-up on a 1-week-old girl with bronchiolitis and fever to 38.5, your next step in management is to:

1. Observe and provide supportive care with frequent suctioning and supplemental oxygen
2. Initiate treatment with ceftriaxone 50 mg/kg/dose IV q24 hrs
3. Initiate treatment with ceftriaxone 50 mg/kg/dose IV q12 hrs
4. Initiate treatment with ampicillin 100 mg/kg/dose IV q6 hrs and cefotaxime 50 mg/kg/dose IV q6 hrs
5. Initiate treatment with acyclovir 20 mg/kg/dose IV q8 hrs

2. A 2-week-old full-term male neonate has been hospitalized for 2 days after being brought to the emergency department for evaluation of fever. He was well until 1 day prior to admission when he developed fussiness and was noted to have a temperature of 38.5°C at home. In the emergency department, blood and urine specimens were obtained; however, his parents refused permission to perform a lumbar puncture. He has been receiving ampicillin 50 mg/kg/dose intravenously every 6 hours and gentamicin 4 mg/kg intravenously daily. He has had ongoing fever during the hospitalization, and his parents state that he continues to be fussy. He has a temperature of 38°C, heart rate of 153 beats/min, respiratory rate of 42 breaths/min, and blood pressure of 88/61 mm Hg. He is irritable, and there are scattered red macules with overlying pustules over the thorax. The remainder of the physical examination findings are normal.

Laboratory data are shown:

• Blood culture     Pending
• Urine culture      Escherichia coli
• Escherichia coli susceptibilities are shown:
  • Ampicillin                                    ≥ 32, resistant
  • Ceftriaxone                                 ≥ 64, resistant
  • Ciprofloxacin                               ≤ 0.25, susceptible
  • Gentamicin                                 ≤ 1, susceptible
  • Meropenem                                 ≤ 0.25, susceptible
  • Nitrofurantoin                              ≤ 32, susceptible
  • Trimethoprim-sulfamethoxazole    ≤ 20, susceptible

Of the following, the MOST appropriate antibiotic to use as monotherapy for this patient’s infection is:      

1. gentamicin
2. meropenem
3. nitrofurantoin
4. trimethoprim-sulfamethoxazole

Find the answers here