Pediatric fever of uncertain source

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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
  • Preemies: Count age by estimated postconception date (not by actual delivery date) for 1st-90d
  • If RSV+ or influenza+
    • 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

  1. CBC
  2. Blood Cx
  3. UA, Ucx
  4. LP-CSF
  5. CXR^
  1. Cefotaxime^^ 50-100 mg/kg
  2. Ampicillin 100-200 mg/kg
  3. Acyclovir^^^ 20 mg/kg
 Admit N/A
  • ^CXR for (use clinical judgment):
    • Resp symptoms
    • Fever >48 hrs
    • Tachypnea
    • Decreased SaO2
  • ^^Can use ceftriaxone 50-100 mg/kg, but concern for bilirubin displacement
  • ^^^Acyclovir if:
    • HSV infection in baby or mother
    • CSF pleocytoisis
    • Concerning skin lesions
    • Seizures
    • Abnl LFTs

28dy-90dy

Appearance Work Up Treatment Disposition Follow Up
T>=38 + Toxic
  1. CBC
  2. Blood Cx
  3. UA, Ucx
  4. LP-CSF
  5. CXR^
  1. Cefotaxime^^ 50-100 mg/kg
  2. Ampicillin 100 mg/kg
  3. Acyclovir^^^ 20 mg/kg
 Admit NA

T>=38 + Well

(Option 1)

  1. CBC
  2. Blood Cx
  3. UA, UCx
  4. LP-CSF
  5. CXR^
  1. Ceftriaxone (50mg/kg IM/IV)

If W/U (+) admit

Outpatient^^^^

If W/U negative, meets outpt

T>=38 + Toxic

(Option 2)

  1. CBC
  2. Blood Cx
  3. UA, UCx
  4. CXR^
  1. None

For very well appearing 60-90 day olds (many would not use this option)

Outpatient^^^^
  • ^CXR for (use clinical judgment):
    • Resp symptoms
    • Fever >48 hrs
    • Tachypnea
    • Decreased SaO2
  • ^^Can use ceftriaxone 50-100 mg/kg, but concern for bilirubin displacement
  • ^^^Acyclovir if:
    • HSV infection in baby or mother
    • CSF pleocytoisis
    • Concerning skin lesions
    • Seizures
    • Abnl LFTs
  • ^^^^Outpatient

90dy-36mo

Appearance Work Up Treatment Disposition Follow Up
T>=39 + Toxic
  1. CBC
  2. Blood Cx
  3. UA, UCx
  4. LP-CSF
  5. CXR^

Ceftriaxone (50-100mg/kg)

OR

Cefotaxime (50-100mg/kg)

AND

Consider Vanco (15mg/kg)^^^^

Admit N/A

T>=39^^^^^ + Well + Prevnar^^

  1. UA, UCx^^^
  2. CXR^

If + W/U, oral abx

Outpatient

T>=39^^^^^ + Well + NO Prevnar^^

  1. UA, UCx^^^
  2. CBC
  3. CXR^

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
  • ^CXR for (use clinical judgment):
    • Resp symptoms
    • Fever >48 hrs
    • Tachypnea
    • Decreased SaO2
  • ^^Prevnar = has 3 Prevnar or >=4 wks post 2nd Prevnar dose
  • ^^^Urine workup for:
    • Circumcised males <6 months
    • Uncircumcised males <12 months
    • All females
  • ^^^^Vancomycin if evidence of bacterial meningitis on CSF
  • ^^^^^>=39.5 for 24-36mo

Work-Up Results

  • 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

Petechia

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

See Also

Source

  • Tintinalli
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