Fever 0-3 months
What should be done?
Donna Moro-Sutherland, MD
Pediatric Emergency Medicine Physician
WakeMed Health & Hospitals
Antibiotic Choices
Ampicillin: 100 mg/kg/dose
 Gentamicin: 2.5 mg/kg/dose
 Cefotaxime: 100 mg/kg/dose
 Ceftriaxone: 100 mg/kg/dose

– Not recommended for neonates who have
jaundice

Vancomycin: 10-15 mg/kg/dose
Empiric Antibiotic Protocols:
Rule out sepsis (ROS)

0-28 days:
– Ampicillin and gentamycin

29-60 days:
– Ampicillin and cefotaxime/ceftriaxone

60+ days
– Cefotaxime or Ceftriaxone
Empiric Antibiotic Protocols

Meningitis < 1 month:
– Ampicillin + Gentamicin

Meningitis > 1 month:
– Vancomycin + Cefotaxime
– add Gent if GNR
Neonatal Herpes Simplex

Acyclovir: 20 mg/kg for HSV
What are the laboratory tests used
to determine low risk?
CBC 5-15,000/mm3
 ABC < 1500 or B/N ratio < 0.2
 UA < 10 WBC/hpf
 Stool < 5 WBC/hpf
 CSF < 8 WBC

Blood, urine and CSF cultures
Temp > 38.00C and age 0-3 months
Yes
Age < 28 days or
Toxic appearance
CBC with diff
BC
UA, UC
CSF studies
CXR & stool if indicated
Consider HSV studies
IV antibiotics
Admission
Yes
No
Baseline
High Risk
No
29 days- < 2 months
Option 1
CBC with diff
BC
UA, UC
+CSF studies*
2- 3 months
Option 2
CBC with diff
BC
UA, UC
CXR & stool if indicated
(Understand most will get LP upfront)
CXR & stool if indicated
Abnormal lab or xray
CSF studies
IV Antibiotics
Yes
Hospital admission
29 days- < 2 months
2- 3 months
Option 1
CBC with diff
BC
UA, UC
+CSF studies
(Understand most will get LP upfront)
CXR & stool if indicated
Abnormal lab or xray
Option 2
CBC with diff
BC
UA, UC
CXR & stool if indicated
Yes
CSF studies
IV Antibiotics
Hospital admission
No
No
Follow up assured in 24h
Adequate social situation
Parent and PMD agree to outpatient approach
Consider Ceftriaxone but only if LP is performed
Yes
Discharge
2-3 months
Option 1
Option 2
CBC with diff
BC
UA, UC
CSF studies
CXR &
stool if indicated
CBC with diff
BC
UA, UC
Option 3
UA, UC
What if the infant has RSV?....
< 28 days
29 days - 2 months
RSV+
RSV+
Option 1
CBC with diff
BC
UA, UC
CSF studies
CXR
Stool if indicated
IV antibiotics
Admission
UA, UC
Rarely done!
Option 2
CBC with diff
BC
UA, UC
29 days - 2 months
RSV+
Option 1
UA, UC
CBC with diff
BC
CSF studies
CXR
IV antibiotics
Admission
Yes
Option 2
CBC with diff
BC
UA, UC
Abnormal labs
What do we know…

0-28 days with fever
– Risk too great for SBI

29-90 days
– Low risk groups can be identified
– Presence of RSV, influenza and other
recognizable viral illnesses is associated
with a decreased incidence of SBI, but not
absence of SBI
What else do we know…

0-28 days with fever
– Sepsis work up
– Consider Viral testing
– Admission and antibiotics

29-59 days
– Sepsis work up (CSF cultures may be omitted in a
select population)
– If Viral testing done:
• If high risk: admit and treat with antibiotics
• If low risk: admit/observe vs discharge and follow up
Finally….

60-89 days
– More mature, immunologically and socially
– Most fever caused by viral illness
– Incidence of SBI lower
– No consensus for evaluation of fever
without a source
• UA with urine culture in all….
• CBC with BC
Empiric Antibiotic Protocols:
Rule out sepsis (ROS)

0-28 days:
– Ampicillin and gentamycin

29-60 days:
– Ampicillin and cefotaxime/ceftriaxone

60+ days
– Cefotaxime or Ceftriaxone
Empiric Antibiotic Protocols

Meningitis < 1 month:
– Ampicillin + Gentamicin

Meningitis > 1 month:
– Vancomycin + Cefotaxime
– add Gent if GNR