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)
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 |
|
|
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 |
|
|
Admit | NA |
T>=38 + Well (Option 1) |
|
|
If W/U (+) admit Outpatient^^^^ |
If W/U negative, meets outpt |
T>=38 + Toxic (Option 2) |
|
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 |
|
Ceftriaxone (50-100mg/kg) OR Cefotaxime (50-100mg/kg) AND Consider Vanco (15mg/kg)^^^^ |
Admit | N/A |
T>=39^^^^^ + Well + Prevnar^^ |
|
If + W/U, oral abx |
Outpatient | |
T>=39^^^^^ + Well + NO Prevnar^^ |
|
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
- CBC
- BCx
- Ceftriaxone
- LP depending on clinical
Facts and Figures from ACEP's Clinical Policy on Pediatric Fevers
7% of patients < 2 years old with fever have PNA, however the etiology (viral/bacterial) or even the presence of PNA has low inter-observer reliability among pediatric radiologists
4% Prevalence of UTI with common other sources of fever (OM, viral URI, et cetera)
1.5-2% background prevalence of asymptomatic bacteruria in healthy afebrile controls
0.3% Rate of occult bactremia with healthy, well-appearing child who has a fever 2-24 months
0.3% of previously well children aged 3-36 months who have a fever without a source will develop significant sequelae
0.03% will develop sepsis or meningitis
See Also
External Links
1.PEM ED Podcast and easy-to-follow diagnostic/treatment flow chart http://www.pemed.org/blog/2011/10/9/fever-of-unknown-source-part-1.html
Source
- Tintinalli
- Clinical Policy for Children Younger Than Three Years Presenting to the Emergency Department With Fever. Annuals of Emergency Medicine 2003 42. 530-545