Pediatric fever of uncertain source

From Tintinalli

Management of patients who are well-appearing, vaccinated, and no clinical source of fever

Age Group	Evaluation	Treatment
0-28d, ≥38C SBI incidence of ill appearing: 13%–21% if not ill appearing: <5%	CBC, blood Cx UA, Ucx CSF cell count, GS, Cx CXR (only if resp sx) Stool testing (if diarrhea present)	Admit Ampicillin 50mg/kg + (cefotaxime 50mg/kg or gentamicin 2.5mg/kg)
29-56d, ≥ 38.2 (100.8) (Philadelphia Protocol) SBI incidence of ill appearing: 13%–21% if not ill appearing: <5%	Same as for neonates	Discharge if: 1. WBC <15K but >5K and <20% bands 2. UA negative Admit and perform LP if above are not met Treat with CTX 50mg/kg (if CSF normal), 100mg/kg (if signs of meningitis)
57d-6mo, ≥38 Non-UTI SBI incidence is estimated to be negligible UTI is 3%–8%	UA and Ucx alone OR treat 57-90d using Philadelphia Protocol	Discharge if negative Treat UTI w/ cefixime 8mg/kg/d or cefpodoxime 10mg/kg/d divided into BID or cefdinir 14mg/kg/d x 7-10days as outpatient Admit and tx with CTX if fail criteria for d/c
57d-6mo, ≥39 (102.2) SBI incidence is estimated <1%; non-UTI SBI incidence is estimated to be negligible. UTI is 3%–8%	UA and Ucx alone OR UA and Ucx + CBC + blood cx	Discharge if negative Treat for UTI as above If WBC>15K consider treatment with CTX 50 mg/kg IV/IM, and follow-up in 24hr If WBC>20K consider CXR and CSF
6–36 mo Non-UTI SBI incidence is <0.4%  UTI in girls ≤8% UTI in boys (<12 mo) ≤ 2% Uncircumcised boys (1–2 y) remains 2%	UA and Ucx in: (girls 6-24mo) (circ 6-12mo) (uncirc 6-24mo)	Discharge if negative Treat for UTI as above as outpatient
>36mo	No further w/u is routinely necessary

Note: Preemies - Count age by estimated postconception date (not by actual delivery date) for 1st 90d

Harbor-UCLA Protocol

0-28dy

Child Appearance	Work Up	Treatment	Disposition	Follow Up
T>=38 Toxic or Well	CBC Blood Cx UA, Ucx LP-CSF CXR (only if resp sx)	Cefotaxime^ 50-100 mg/kg Ampicillin 100-200 mg/kg Acyclovir^^ 20 mg/kg	Admit	N/A

28dy-90dy

Appearance	Work Up	Treatment	Disposition	Follow Up
T>=38 + Toxic	CBC Blood Cx UA, Ucx LP-CSF CXR (only if resp sx)	Cefotaxime^ 50-100 mg/kg Ampicillin 100 mg/kg Acyclovir^^ 20 mg/kg	Admit	NA
T>=38 + Well (Option 1)	CBC Blood Cx UA, Ucx LP-CSF CXR (only if resp sx)	Ceftriaxone (50mg/kg IM/IV)	If W/U + admit Outpatient^^^	If W/U negative, meets outpt
T>=38 + Toxic (Option 2)	CBC Blood Cx UA, Ucx CXR (only if resp sx)	None For very well appearing 60-90 day olds (many would not use)	Outpatient^^^

Age Group	Evaluation	Treatment
T>=38 + Toxic	CBC Blood Cx UA, Ucx LP-CSF CXR (only if resp sx)	Discharge if: WBC <15K but >5K and <20% bands UA negative Admit if: Above are not met Treat CTX 50mg/kg if CSF normal 100mg/kg if signs of meningitis
T>=38 + Well	CBC Blood Cx UA, Ucx LP-CSF (cell count, GS, Cx) CXR (only if resp sx)	Discharge if: WBC <15K but >5K and <20% bands UA negative Admit if: Above are not met Treat CTX 50mg/kg if CSF normal 100mg/kg if signs of meningitis
57d-6mo, ≥38 Non-UTI SBI incidence is estimated to be negligible	UA and Ucx alone OR treat 57-90d using Philadelphia Protocol	Discharge if negative Treat UTI w/ cefixime 8mg/kg/d or cefpodoxime 10mg/kg/d divided into BID or cefdinir 14mg/kg/d x 7-10days as outpatient Admit and tx with CTX if fail criteria for d/c
57d-6mo, ≥39 (102.2) SBI incidence is estimated <1%; non-UTI SBI incidence is estimated to be negligible. UTI is 3%–8%	UA and Ucx alone OR UA and Ucx + CBC + blood cx	Discharge if negative Treat for UTI as above If WBC>15K consider treatment with CTX 50 mg/kg IV/IM, and follow-up in 24hr If WBC>20K consider CXR and CSF

90dy-36mo

Age Group	Evaluation	Treatment
57d-6mo, ≥39 (102.2) SBI incidence is estimated <1%; non-UTI SBI incidence is estimated to be negligible. UTI is 3%–8%	UA and Ucx alone OR UA and Ucx + CBC + blood cx	Discharge if negative Treat for UTI as above If WBC>15K consider treatment with CTX 50 mg/kg IV/IM, and follow-up in 24hr If WBC>20K consider CXR and CSF
6–36 mo Non-UTI SBI incidence is <0.4%  UTI in girls ≤8% UTI in boys (<12 mo) ≤ 2% Uncircumcised boys (1–2 y) remains 2%	UA and Ucx in: (girls 6-24mo) (circ 6-12mo) (uncirc 6-24mo)	Discharge if negative Treat for UTI as above as outpatient
>36mo	No further w/u is routinely necessary

Note: Preemies - Count age by estimated postconception date (not by actual delivery date) for 1st 90d

^Can use ceftriaxone 50-100 mg/kg, but concern for bilirubin displacement ^^Add acyclovir if HSV infection in baby or mother, CSF pleocytoisis, concerning skin lesions, seizures, abnl LFTs

See Also

• UTI (Peds)
• Sepsis (Peds)
• Meningitis (Peds)
• Febrile Seizure

Source

Tintinalli