ED Management of Fever
Without Apparent Serious Bacterial Source
In the Previously Well Child Aged 0-36 Months
Fever1
Yes
Toxic
appearing2?
Sepsis W/U3
IV Abx,4 Admit
No
Age < 28 days
Age 29-60 days
Sepsis W/U,3
IV Abx,4
Admit
Sepsis W/U3
Age 2-36 mos
Yes
Identifiable viral infection5?
No
Low risk for
No
SBI6?
Clinical
Judgment
Yes
Yes
Abx4
IV
Admit
No Abx
Eval 24 hrs
Minor bacterial
focus7?
No
PO/IM Abx,
Consider
Bld Cx
Yes
Treat UTI
+ UA?8
Risk for UTI?9
Cath UA/Ur Cx
No
Yes
Treat Pneumonia
+CXR
CXR (AP/Lat)
Risk for Pneumonia?10
No
ANC > 10,000/mm3
Yes
CBC/Hold Bld Cx
Risk for Occult Bacteremia?11
No
Send Bld Cx,
IM/IV Abx,12
Eval 24 hrs
Clinical Judgment
1
Guideline for ED Management of Fever Without Source in Infants Aged 0-36 Months
Notes:
1 Fever=rectal temp. > 38C/100.4F
2 Toxicity=altered mental status; poor eye contact; inappropriate response to
stimuli; abnormal vital signs; poor skin perfusion; cyanosis; grunting
3 Sepsis W/U includes: CBC/diff: bld cx; cath UA/urine cx; LP (CSF gm stain/
cx/protein/glucose/cell count/consider HSV or enteroviral PCR); CXR (AP/Lat)
for resp. signs/sx (see footnote 14); stool cx for stool blood/pus
4 IV Abx (suggested):
(1) Age < 28 days: Ampicillin 50 mg/kg/dose IV Q12H (< 1 wk) or 50 mg/kg/dose
IV Q6H (> 1 wk) + Cefotaxime 50 mg/kg/dose IV Q12H (< 1 wk) or 50
mg/kg/dose IV Q8H (> 1wk) OR + Gentamycin 2.5 mg/kg/dose IV Q12H (< 1
wk) or 2.5 mg/kg/dose IV Q8H (> 1 wk); add Acyclovir if suspect HSV
(2) Age 29-60 days: Ampicillin 50 mg/kg/dose IV Q6H + cefotaxime 60 mg/kg/
dose IV Q8H (or + Gentamycin 2.5 mg/kg/dose IV Q8H if CSF is free of signs
of meningitis)
5 Identifiable viral infection includes: bronchiolitis; croup; VZV; herpangina;
hand-foot-mouth disease; HSV gingivostomatitis; adenovirus (Note: URI or
viral gastroenteritis have not been identified as a fever “source” in infants 0-36
months of age)
6 Low risk criteria for serious bacterial illness: no bacterial focus on PE (excludes
otitis media); CSF < 8 WBC/mm3 in nonbloody specimen; negative CSF Gm
stain; peripheral WBC < 15,000/mm3; BNR (band to neutrophil ratio) < 0.2;
normal UA (negative nitrite and/or < 10 WBC/hpf); no infiltrate on CXR; when
diarrhea present no heme and few or no stool WBC/hpf; reliable & easily
contacted caretaker
7 Minor bacterial focus: otitis media; pharyngitis; sinusitis
8 +UA=(any of the following): + nitrite; > mod LE; + gm stain; > 10 WBC/hpf
(spun specimen); > 10 WBC/mm3 (unspun specimen, “enhanced UA”)
9 Risk for UTI (any of the following): female (particularly aged < 24 mos); male
aged < 6 mos or uncircumcized; malodorous urine; hematuria; abdominal or
suprapubic tenderness; hx UTI; GU abnormality
10 Risk for pneumonia (any of the following): increased WOB (e.g. tachypnea,
retractions); focal auscultatory findings; Sa02<97% (RA); WBC > 20,000/mm3
11 Risk for occult bacteremia (both should be present):
(1) < 2 doses of Prevnar (pneumococcal 7-valent conjugate vaccine)
(2) temp > 39 C/102.2 F (age 2-24 mos) or > 39.5 C/103 F (age 24-36 mos)
12 IM/IV Abx: consider Ceftriaxone 50 mg/kg IM/IV (to 1 gm)
References:
Occult Bacteremia
2
Guideline for ED Management of Fever Without Source in Infants Aged 0-36 Months
Bonadio WA. Evaluation and management of serious bacterial infections in the
febrile young infant. Pediatr Infect Dis J 1990;9:905-912
[For infants < 28 days with fever, perform sepsis work-up and admit on IV antibiotics.]
Teach SJ, Fleisher GR. Efficacy of an observation scale in detecting bacteremia in
febrile children three to thirty-six months of age, treated as outpatients. J Pediatr
1995;126:877-881
[Yale Observation Scale is not clinically useful in detecting occult bacteremia in nontoxic febrile infants aged 0-36 months with nonfocal infection.]
Kuppermann N, Bank DE, Walton EA, et al. Risks for bacteremia and urinary
tract infections in young febrile children with bronchiolitis. Arch Pediatr Adolesc
Med 1997;151:1207-1214
[Febrile children with bronchiolitis do not need a fever work-up.]
Rothrock SG, Harper MB, Green SM, et al. Do oral antibiotics prevent meningitis
and serious bacterial infections in children with Streptococcus pneumoniae occult
bacteremia? A meta-analysis. Pediatrics 1997;99:438-44
[Although oral antibiotics modestly decreased the risk of SBI in children with S.
pneumoniae occult bacteremia, there was insufficient evidence to conclude that oral
antibiotics prevent meningitis.]
Lee GM, Harper MB. Risk of bacteremia for febrile young children in the postHaemophilus influenzae Type b era. Arch Pediatr Adolesc Med 1998;152:624-628
[The prevalence of occult bacteremia in children aged 3-36 months with temperatures >
39.0 C. and no obvious source of infection is 1.6%. The WBC count and ANC are the
best predictors for OPB.]
Rothrock SG, Green SM, Harper MB, et al. Parenteral vs oral antibiotics in the
prevention of serious bacterial infections in children with Streptococcus
pneumoniae occult bacteremia: a meta-analysis. Acad Emerg Med 1998;5:599-606
[The rates of serious bacterial infections and meningitis did not differ between children
who were treated with oral and parenteral antibiotics. The extremely low rate of
complications observed in both groups suggests no clinically significant difference
between therapies. A study with >7,500 bacteremic children (or >300,000 febrile
children) would be needed to have 80% power to prove parenteral antibiotics are superior
to oral antibiotics in preventing serious bacterial infections.]
Kuppermann N, Fleisher GR, Jaffe DM. Predictors of occult pneumococcal
bacteremia in young febrile children. Ann Emerg Med 1998;31:679-687
[Height of fever and ANC>10,000/mm3 are independent predictors of OPB in febrile
children 3-36 months of age.]
Greenes DS, Harper MB. Low risk of bacteremia in febrile children with
recognizable viral syndromes. Pediatr Infect Dis J 1999;18:258-261
[Febrile children with recognizable viral syndromes do not need a fever work-up.]
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Guideline for ED Management of Fever Without Source in Infants Aged 0-36 Months
Baker MD, Bell LM, Avner JR. The efficacy of routine outpatient management
without antibiotics of fever in selected infants. Pediatrics 1999;103:627-631
[“Low risk” infants 29-60 days can be managed as outpatients without antibiotics.]
Kuppermann N. Occult bacteremia in young febrile children. Pediatr Clin North
Am 1999; 46:1073-1109
[Summary of topic.]
Baraff LJ. Management of fever without source in infants and children. Ann
Emerg Med 2000;36:602-614
[Summary of topic with proposed guideline.]
Isaacman DJ, Shults J, Gross TK, et al. Predictors of bacteremia in febrile children
3-36 months of age. Pediatrics 2000;106:977-982
[Predictors of bacteremia identified by logistic regression included ANC 9.46, WBC
14.3, PMN 59%, and temperature 39.6 C., and female gender. ROC analysis showed
similar performance of ANC and WBC as predictors of bacteremia. A logistic regression
formula was developed that could be used to develop a unique risk value for each patient
based on temperature, gender, and ANC.]
Alpern ER, Alessandrini A, Bell LM, et al. Occult bacteremia from a pediatric
emergency department: current prevalence, time to detection, and outcome.
Pediatrics 2000;106:505-511
[Prevalence of occult bacteremia was 1.9% (95% CI 1.5%-2.3%). S. pneumoniae
accounts for 82.9% of all pathogens. Using a continuously monitoring blood culture
system, the mean time to positive culture was significantly shorter for pathogens
compared with contaminants (14.9 hrs vs. 31.1 hrs). A culture that was positive in < 18
hrs was 13.0 times more likely to contain a pathogen than a contaminant. Of patients
with OPB, 95.7% had resolution of their bacteremia without use of parenteral antibiotics.
Two patients had serious adverse outcomes. The rate of meningitis or death was .03%.]
Lee GM, Fleisher GR, Harper MB. Management of febrile children in the age of
the conjugate pneumococcal vaccine: a cost-effectiveness analysis. Pediatrics 2001;
108: 835-44
["CBC + selective blood culture and treatment" using a WBC cutoff of 15 x 10(9)/L is
cost-effective at the current rate of pneumococcal bacteremia. If the rate of occult
bacteremia falls below 0.5% with widespread use of the conjugate pneumococcal
vaccine, then strategies that use empiric testing and treatment should be eliminated.]
Alpern ER, Alessandrini EA, McGowan KL, et al. Serotype prevalence of occult
pneumococcal bacteremia. Pediatrics 2001;108:e23
[The heptavalent pneumococcal conjugate vaccine may prevent the majority of occult
pneumococcal bacteremia episodes. There has been an alarming and rapid emergence of
antibiotic-resistant pneumococcal strains. The prevalence rates determined by this study
may be used as baseline data for comparison of serotype rates of occult pneumococcal
bacteremia after widespread use of the heptavalent vaccine.]
4
Guideline for ED Management of Fever Without Source in Infants Aged 0-36 Months
Pulliam PN, Attia MW, Cronan KM. C-reactive protein in febrile children 1 to 36
months of age with clinically undetectable serious bacterial infection. Pediatrics
2001;108:1275-9
[In febrile infants, quantitative CRP has better predictive value than WBC or ANC in the
detection of occult SBI.]
Isaacman DJ, Burke BL. Utility of the serum C-reactive protein for detection of
occult bacterial infection in children. Arch Pediatr Adolesc Med 2002;156:905-9
[In 256 febrile infants aged 3-36 months (median age of 15.3 months, age range 3.1-35.2
months & median temp. 40.0  C), 29 (11.3%) cases of occult bacterial infection (OBI)
were identified, including 17 cases of pneumonia, 9 cases of urinary tract infection, and 3
cases of bacteremia. Median WBC was 12.9 x 10(3)/uL, median ANC was 7.12 x
10(3)/L, and median CRP level was 1.7 mg/dL. Overall bacteremia rate was 1.1%. An
ANC cut-off point of 10.6 x10(3)/L [corrected] offers the best predictive model for
detection of occult bacterial infection using a single test. The addition of CRP to ANC
adds little diagnostic utility.]
Whitney CG, Farley MM, Hadler J, et al. Decline in invasive pneumococcal disease
after the introduction of protein-polysaccharide conjugate vaccine. N Engl J Med
2003;348:1737-46
[In children aged < 2 years, the rate of IPD was 69% lower in 2001 than the baseline rate
(59 cases per 100,000 vs. 188 per 100,000, p<0.001), & the rate of disease caused by
vaccine & vaccine-related serotypes declined by 78% (p<0.001) & 50% (p<0.001),
respectively.]
Fernández LA, Luaces CC, García García JJ, et al. Procalcitonin in pediatric
emergency departments for the early diagnosis of invasive bacterial infections in
febrile infants: results of a multicenter study and utility of a rapid qualitative test
for this marker. Pediatr Infect Dis J 2003;22:895-903
[PCT offers better specificity than CRP for differentiating between the viral & bacterial
etiology of the fever (< 12 h) with similar sensitivity. PCT offers better sensibility &
specificity than CRP to differentiate between invasive and noninvasive infection. The
PCT-Q test has a good correlation with the quantitative values of the marker.]
Neuman MI, Harper MB. Evaluation of a rapid urine antigen assay for the
detection of invasive pneumococcal disease in children. Pediatrics 2003;112:1279-82
[A S. pneumoniae antigen detection assay demonstrated high sensitivity for proven
(bacteremic) and suspected (focal pneumonia) invasive pneumococcal infections. The
rate of false-positive test results among febrile children without identified pneumococcal
infection is approximately 15%. Although not ideal, this combination of sensitivity and
specificity compares favorably with other available tests, such as the WBC or absolute
neutrophil count used to screen children for clinically unsuspected pneumococcal
infections.]
5
Guideline for ED Management of Fever Without Source in Infants Aged 0-36 Months
Bonsu BK, Harper MB. Identifying febrile young infants with bacteremia: is the
peripheral white blood cell count an accurate screen? Ann Emerg Med 2003;42:21625
[The total peripheral WBC count is an inaccurate screen for bacteremia in febrile young
infants. Decisions to obtain blood cultures should not rely on this test.]
Urinary Tract Infection
Crain E, Gershel J. Urinary tract infections in febrile infants younger than 8 weeks
of age. Pediatrics. 1990;86:363-7
[Of 33/430 febrile infants < 8 weeks of age with positive urine cx results, only 16 had an
abnormal UA (defined as > 5 WBC/hpf or visible bacteria).]
Shaw KN, Hexter D, McGowan KL, et al. Clinical evaluation of a rapid screening
test for urinary tract infections in children. J Pediatr 1991;118:733-6
Hoberman A, Chao HP, Keller DM, et al. Prevalence of urinary tract infection in
febrile infants. J Pediatr 1993;123:17-23
[UTI was diagnosed in 50/945 (5.3%) febrile infants (temp > 38.3  C) if we found >
10,000 CFU/mL in a cath urine specimen. Female and white infants had significantly
more UTIs, respectively, than male and black infants. 17% of white female infants with
temperature > 39  C had UTI, significantly more (p < 0.05) than any other grouping of
infants by sex, race, and temperature. Febrile infants with no apparent source of fever
were twice as likely to have UTI (7.5%) as those with a possible source of fever such as
otitis media (3.5%) (p = 0.02). Only 1/62 (1.6%) subjects with an unequivocal source of
fever, such as meningitis, had UTI. As indicators of UTI, pyuria and bacteriuria had
sensitivities of 54% and 86% and specificities of 96% and 63%, respectively. In infants
with fever, clinicians should consider UTI a potential source and consider a urine culture
as part of the diagnostic evaluation.]
Wiswell T, Hachey W. Urinary tract infections and the uncircumcised state: an
update. Clin Pediatr 1993;32:130-4
[Uncircumcised boys have an approximately 10-fold increase in rate of UTI.]
Amir J, Ginzburg M, Straussberg R, et al. The reliability of midstream urine
culture from circumcised male infants. Am J Dis Child 1993;147:969-70
[In circumcised male infants, the midstream method of obtaining urine for a culture is as
reliable as SPA.]
Landau D, Turner M, Brennan J, et al. The value of urinalysis in differentiating
acute pyelonephritis from lower tract infection in febrile infants. Pediatr Infect Dis
J 1994;13:777-81
[13/128 (24%) infants with positive results on culture had < 5 WBC/hpf. 49/128 infants
had DMSA radionuclide scans which indicated pyelonephritis. 27/31 infants (87%)
without pyuria had normal DMSA scans, suggesting most infants with positive cx results
6
Guideline for ED Management of Fever Without Source in Infants Aged 0-36 Months
but no pyuria may have had asymptomatic bacteriuria. 4/31 infants (13%) without pyuria
did have positive results on DMSA scan, underscoring the difficulty of assuming that
bacteriuria without pyuria excludes true UTI.]
Hoberman A, Wald ER, Reynolds EA, et al. Is urine culture necessary to rule out
urinary tract infection in young febrile children? Pediatr Infect Dis J 1996;15:304-9
[In a group of 4253 children (95% febrile) less than 2 years of age, pyuria was defined as
> 10 WBC/mm3, bacteriuria as any bacteria on any of 10 oil immersion fields in a Gramstained smear and a positive cx as > 50,000 colony-forming units/ml. The presence of
either pyuria or bacteriuria and the presence of both pyuria and bacteriuria have the
highest sensitivity (95%) and positive predictive value (85%), respectively, for
identifying positive urine cx. The analysis of urine samples obtained by catheter for the
presence of significant pyuria (> 10 WBCs/mm3) can be used to guide decisions
regarding the need for urine cx in young febrile children.]
Hoberman A, Wald ER. Urinary tract infections in young febrile infants. Pediatr
Infect Dis J 1997;16:11-7
[PPV of the combination of pyuria & bacteriuria (85%) allows prompt institution of
antimicrobial therapy before cx results are available, whereas the lower positive
predictive value of the single finding of either pyuria or bacteriuria (40%) justifies
delaying treatment decisions until cx results are available. Culturing only specimens with
pyuria (by enhanced urinalysis) and those of children presumptively treated with
antimicrobials will result in the identification of almost all patients with true UTI.
Although the urine cx is traditionally regarded as the gold standard of UTI, positive urine
cx may occur secondary to contamination or in cases of asymptomatic bacteriuria (ABU),
leading to a false diagnosis of UTI. In contrast we found pyuria to be a reliable marker to
discriminate infection from colonization of the urinary tract. Management of ABU is
controversial; many experts recommend withholding antibiotics because eradication of
low virulence organisms may be followed by colonization with more virulent species that
cause pyelonephritis. Accordingly selective rather than routine performance of ultrasound
is recommended. A voiding cystourethrogram at 1 month and a DMSA scan 6 months
later have been valuable in identifying patients with vesicoureteral reflux and renal
scarring, respectively. Among patients initially identified as having acute pyelonephritis,
the incidence of renal scarring at 6 months has been substantially more frequent
(approximately 40%) than we had expected. However, the long term implications of
small scars identified with renal scintigraphy remain to be determined.]
To T, Agha M, Dick PT, et al. Cohort study on circumcision of newborn boys and
subsequent risk of urinary-tract infection. Lancet 1998;352:1813-6
[Of 69,100 eligible boys (30,105 circumcised and 38,995 uncircumcised), 29,217
uncircumcised boys were matched to the remaining circumcised boys by date of birth.
The 1-year probabilities of hospital admission for UTI were 1.88 per 1000 person-years
of observation (83 cases up to end of follow-up) in the circumcised cohort and 7.02 per
1000 person-years (247 cases up to end of follow-up) in the uncircumcised cohort
(p<0.0001). The estimated relative risk of admission for UTI by first-year follow-up
7
Guideline for ED Management of Fever Without Source in Infants Aged 0-36 Months
indicated a significantly higher risk for uncircumcised boys than for circumcised boys
(3.7 [2.8-4.9]). ]
Shaw KN, McGowan KL, Gorelick MH, et al. Screening for urinary tract infection
in infants in the emergency department: which test is best? Pediatrics 1998;101:e1
[No screening test detects all infants with UTI. In infants with significantly positive
dipstick results, a urine culture should be sent and presumptive antibiotic therapy should
be initiated. The enhanced urinalysis is the most sensitive for detecting UTI, but is less
specific and more costly than routine urinalysis.]
Shaw KN, Gorelick M, McGowan KL, et al. Prevalence of urinary tract infection
in febrile young children in the emergency department. Pediatrics 1998;102:e16.
[In a cross-sectional prevalence survey of 2411 (83%) of all infants aged < 12 months
and girls younger aged < 2 years presenting to the ED with a fever (> 38.5  C) with
FWOS and not on antibiotics or immunosuppressed, overall prevalence of UTI (> 104
CFU/mL of a urinary tract pathogen) was 3.3% (95% CI 2.6, 4.0). Higher prevalences
occurred in whites (10.7%; 95% CI 7.1, 14.3), girls (4.3%; 95% CI 3.3, 5.3),
uncircumcised boys (8.0%; 95% CI 1.9, 14.1), and those without another potential source
for their fever (5.9%; 95% CI 3.8, 8.0), had a history of UTI (9.3%; 95% CI 3.0, 20.3),
malodorous urine or hematuria (8.6%; 95% CI 2.8, 19.0), appeared "ill" (5.7%; 95% CI
4.0, 7.4), had abdominal or suprapubic tenderness on examination (13. 2%; 95% CI 3.7,
30.7), or had fever > 39  C (3.9%; 95% CI 3. 0, 4.8). White girls had a 16.1% (95% CI
10.6, 21.6) prevalence of UTI. Specific clinical signs and symptoms of UTI are
uncommon, and the presence of another potential source of fever such as upper
respiratory infection or otitis media is not reliable in excluding UTI.]
AAP Committee on Quality Improvement. Practice parameter: The diagnosis,
treatment, and evaluation of the initial urinary tract infection in febrile infants and
young children. Pediatrics 1999;103:843-52
[Eleven recommendations are proposed for the diagnosis, management, and follow-up
evaluation of infants and young children (2 months to 2 years) with UTI
1 The presence of UTI should be considered in the setting of unexplained fever.
2 The degree of toxicity, dehydration, and ability to retain oral intake must be carefully
assessed in the setting of unexplained fever.
3 A urine specimen should be obtained by SPA or transurethral bladder catheterization;
the diagnosis of UTI cannot be established by bag urine culture.
4 If immediate antibiotic therapy is not required:
a. obtain a urine culture by SPA or transurethral bladder catheterization, or
b. obtain a urinalysis/urine culture; withold antibiotics if the urinalysis does not
suggest UTI, recognizing that a negative urinalysis does not rule out a UTI
5 Diagnosis of UTI requires a urine culture.
6 Administer parenteral antibiotics and consider hospitalization in the setting of
toxicity, dehydration, or inability to retain oral intake.
7 Initiate parenteral or oral antibiotics in patients who do not appear ill but who have a
positive urine culture.
8
Guideline for ED Management of Fever Without Source in Infants Aged 0-36 Months
8 If the expected clinical response has not been observed after 2 days of antibiotics, a
repeat evaluation should be performed and another urine culture should be obtained.
9 A 7-14 day course of oral antibiotics should be completed in the setting of UTI, even
if initial treatment was administered parenterally.
10 After a 7-14 course of antibiotics and sterilization of urine, prophylactic antibiotics
should be administered until imaging studies are completed.
11 If the expected clinical response has not been seen within 2 days of antibiotic therapy,
ultrasonography should be performed promptly and either voiding cystourethrography
(VCUG) or radionuclide cystography (RNC) should be performed at the earliest
convenient time. If the expected clinical response to antibiotics has been seen,
ultrasonography and either VCUG or RNC should be performed at the earliest
convenient time.]
Shaw KN, Gorelick MH. Urinary tract infection in the pediatric patient. Pediatr
Clin North Am 1999;46:1111-24
[Concise summary of screening strategy for UTI in febrile children.]
Hoberman A, Wald ER, Hickey RW, et al. Oral versus initial intravenous therapy
for urinary tract infections in young febrile children. Pediatrics 1999;104:79-86
[Children 1-24 months of age with fever and UTI can be effectively managed as
outpatients with oral antibiotics (cefixime).]
Gorelick MH, Shaw KN. Screening tests for urinary tract infection in children: a
meta-analysis. Pediatrics 1999;104:e54
[Both gram stain and dipstick analysis for nitrite and LE perform similarly in detecting
UTI in children and are superior to microscopic analysis for pyuria.]
Al-Orifi F, McGillivray D, Tange S, et al. Urine culture from bag specimens in
young children: are the risks too high? J Pediatr 2000;137:221-6
[Among infants aged < 24 mos with outpatient urine cultures (n = 7584, contamination
rates were 62.8% and 9.1% (P <.001) in bag versus catheter specimens, respectively.
Contamination rates of bag urine specimens collected in the ED and pediatric test center
were 56.4% vs. 69.25%, respectively.]
Schoen EJ, Colby CJ, Ray GT. Newborn circumcision decreases incidence and costs
of urinary tract infections during the first year of life. Pediatrics 2000;105:789-93
[Newborn circumcision results in a 9.1-fold decrease in incidence of UTI during the first
year of life as well as markedly lower UTI-related medical costs and rate of hospital
admissions.]
Baker PC, Nelson DS, Schunk JE. The addition of ceftriaxone to oral therapy does
not improve outcome in febrile children with urinary tract infections. Arch Pediatr
Adolesc Med 2001;155:135-9
[The addition of a single dose of IM ceftriaxone to a 10-day course of oral trimethoprimsulfamethoxazole for UTI with fever resulted in no difference at 48 hrs in urine
sterilization rate, degree of clinical improvement, or subsequent hospital admission rate.]
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Guideline for ED Management of Fever Without Source in Infants Aged 0-36 Months
Bachur R, Harper MB. Reliability of the urinalysis for predicting urinary tract
infections in young febrile children. Arch Pediatr Adolesc Med 2001;155:60-5
[Of 11,089 febrile infants with urine cultures (median age and temperature were 10.6
months and 38.8  C), the sensitivity of the UA (+UA= + LE or + nitrite or pyuria (> 5
WBC/hpf) was 82% (95% CI , 79%-84%) and did not vary by age subgroups. The
specificity of UA was 92% (95% CI, 91%-92%). The likelihood ratios for a positive UA
and negative UA were 10.6 (95% CI, 10.0-11.2) and 0.19 (95% CI, 0.18-0.20),
respectively.]
Gorelick NH, Shaw KN. Clinical decision rule to identify febrile young girls at risk
for urinary tract infection. Arch Pediatr Adolesc Med 2000;154:386-90
[In a logistic regression model, the presence of 2 or more of the following 5 variableswhite race; age < 12 months; T > 39.0  C.; absence of another potential source of fever;
duration of fever > 2 days-predicted UTI with a sensitivity of 0.95 (95% CI 0.85-0.99)
and specificity of 0.31 (95% CI 0.28-0.34).]
Tran D, Muchant DG, Aronoff SC. Short-course versus conventional length
antimicrobial therapy for uncomplicated lower urinary tract infections in children:
A meta-analysis of 1279 patients. J Pediatr 2001;139:93-9
[Trimethoprim-sulfamethoxazole for 3 days appears to be as effective as conventional
length courses of the drug for uncomplicated cystitis.]
Newman TB, Bernzweig JA, Takayama JI, et al. Urine testing and urinary tract
infections in febrile infants seen in office settings. Arch Pediatr Adolesc Med
2002;156:44-54
[In infants aged < 3 months with temperatures of > 38  C, height of fever was associated
with urine testing and UTI among those tested (adjusted odds ratio per degree Celsius,
2.2 for both). Younger age, ill appearance, and lack of fever source were associated with
urine testing but not with UTI, whereas lack of circumcision (adjusted odds ratio, 11.6),
female sex (adjusted odds ratio, 5.4), and longer duration of fever (adjusted odds ratio,
1.8 for fever lasting > or = 24 hours) were not associated with urine testing but were
associated with a UTI. Bacteremia accompanied UTI in 10% of the patients, including
17% of those younger than 1 month.]
Gorelick MH, Hoberman A, Kearney et al. Validation of a decision rule identifying
febrile young girls at high risk for urinary tract infection. Pediatr Emerg Care
2003;19:162-4
[A simple clinical decision rule previously developed to predict urinary tract infection
based on five risk factors performs similarly in a different patient population.]
ACEP Clinical Policies Committee (Clinical Policies Subcommittee on Pediatric
Fever). Clinical Policy for Children Younger Than Three Years Presenting to the
Emergency Department With Fever. Ann Emerg Med 2003;42:530-45
[Recommendations for management of UTI in febrile infants & young children are:
1. Children aged < 1 year with FWOS should be considered at risk for UTI.
10
Guideline for ED Management of Fever Without Source in Infants Aged 0-36 Months
2. Females aged 1-2 years presenting with FWOS should be considered at risk for UTI.
3. Urethral catheterization or SPA are the best methods for diagnosing UTI.
4. Obtain a urine cx in conjunction with other urine studies when UTI is suspected in a
child aged < 2 years because a negative urine dipstick or UA result in a febrile child does
not always exclude UTI.]
Pneumonia
Heulitt MJ, Ablow RC, Santos CC, et al. Febrile infants less than 3 months old:
value of chest radiography. Radiology 1988; 167:135-7
[A chest radiograph should be obtained in febrile infants only when signs of respiratory
distress are present.]
Crain EF, Bulas D, Bijur PE, et al. Is a chest radiograph necessary in the
evaluation of every febrile infant less than 8 weeks of age? Pediatrics 1991;88:821-4
[In the absence of respiratory signs, febrile infants aged < 8 weeks are unlikely to have an
abnormal CXR.]
Bramson RT, Meyer TL, Silbiger ML, et al. The futility of the chest radiograph in
the febrile infant without respiratory symptoms. Pediatrics 1993;92:524-6
[A chest radiograph should be obtained only in febrile infants aged < 3 mos with clinical
indications of pulmonary disease.]
Bachur R, Perry H, Harper MB. Occult pneumonias: Empiric chest radiographs in
febrile children with leukocytosis. Ann Emerg Med 1999;33:166-73
[Consider CXR in febrile children with WBC > 20,000/mm3. The results of this study
have been questioned for several reasons. First, the patients included were risk-stratified
in the ED where the study was conducted on the basis of clinical findings. Only 43% of
all febrile infants (>38°C [>100.4°F]) had a WBC count performed, as did only 72% of
those with a temperature greater than 39°C (>102.2°F). In addition, residents rather than
attending physicians performed the majority (56%) of the clinical assessments. More
importantly, no inter-observer reliability data between radiologists determining the
diagnosis of pneumonia were reported. Furthermore, the question has been raised as to
the true utility of determining occult pneumonia in patients without clinical findings.]
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Guideline for ED Management of Fever Without Source in Infants Aged 0-36 Months