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

Background

• Medicine is an art as well as science, practice clinical judgment when using this guideline
• CXR performed based on clinical judgement
  • Recommended for:
    • Resp symptoms
    • Fever >48 hrs
    • Tachypnea
    • Decreased SaO2
• RSV+ or influenze+
  • Low risk of bacterial illness
  • Still some risk of concurrent UTI

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^^^

90dy-36mo

Appearance	Work Up	Treatment	Disposition	Follow Up
T>=39 + Toxic	CBC Blood Cx UA, UCx LP-CSF CXR	Ceftriaxone (50-100mg/kg) OR Cefotaxime (50-100mg/kg) AND Consider Vanco (15mg/kg)^^^^	Admit	N/A
T>=39^ + Well + Prevnar	^^^UA, UCx CXR (if resp sx)	If + W/U, oral abx	Outpatient
T>=39^ + Well + NO Prevnar	^^^UA, UCx CBC CXR (if resp sx)	Ceftriaxone 50mg/kg if >15 WBC (also then consider BCx and LP)	Outpatient
T>=38-38.9 + Well	None Consider UA, CXR based on sx, etc	None	Outpatient	Return if worsening sx or fever persists >72hrs

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

Workup

• WBC: 5-15, ANC <10k, <1,500 bands
• UA: (-)Gm Stain, (-) leuks, (-) nitrite, <5-10 wbc/hpf
• CSF: <8wbc, (-) Gm Stain
• When diarrhea present, <5 wbc

If low-risk criteria below not met, LP (if not done) and admit for inpt abx

^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

Petechia

1. CBC
2. BCx
3. Ceftriaxone
4. LP depending on clinical

See Also

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

Source

Tintinalli