Diseases > Febrile infant

The following summarized guidelines for the evaluation and management of febrile infant are prepared by our editorial team based on guidelines from the American Academy of Pediatrics (AAP 2021) and the American College of Emergency Physicians (ACEP 2016).

1. Diagnostic investigations

Blood tests:

consider obtaining inflammatory markers in well-appearing 8-21 days old infants.

Urine tests:

• As per AAP 2021 guidelines, obtain urinalysis with a specimen collected by catheterization or suprapubic aspiration of bladder in well-appearing febrile 8-21 days old infants. Obtain urine culture if urinalysis is positive.
• As per ACEP 2016 guidelines, consider obtaining urinalysis and urine culture to identify UTI in well-appearing infants and pediatric patients aged 2 months to 2 years with a fever (≥ 38.0 °C or 100.4 °F), especially with a higher risk for UTI (such as females aged < 12 months, uncircumcised males, nonblack race, fever lasting > 24 hours, higher fever of ≥ 39 °C, negative test result for respiratory pathogens, and no obvious source of infection).

Chest radiography:

• Consider obtaining a CXR in well-appearing immunocompetent febrile infants aged 2 months to 2 years presenting with cough, hypoxia, rales, high fever, fever duration > 48 hours, or tachycardia and tachypnea out of proportion to fever, in the absence of an obvious source of infection.
• Do not obtain a CXR in well-appearing immunocompetent febrile infants aged 2 months to 2 years presenting with wheezing or a high likelihood of bronchiolitis.

2. Diagnostic procedures

Cerebrospinal fluid analysis:

As per AAP 2021 guidelines, obtain CSF analysis (WBC, protein, glucose, Gram stain) and bacterial culture in well-appearing febrile 8-21 days old infants.As per ACEP 2016 guidelines:

Consider performing a lumbar puncture in full-term well-appearing febrile 29-90 days old infants.

Avoid performing lumbar puncture in full-term well-appearing febrile 29-90 days old infants diagnosed with a viral illness, given the lower risk for meningitis. Withhold antibiotics if lumbar puncture is deferred unless another bacterial source is identified.

3. Medical management

Setting of care:

hospitalize well-appearing febrile 22-28 days old infants in a facility with nurses and staff experienced in the care of neonates/young infants when CSF is not obtained or is uninterpretable.

Antibiotic therapy (general principles):

obtain active monitoring in well-appearing febrile 8- 21 days old infants while awaiting results of bacterial cultures in a hospital setting with nurses and staff experienced in the care of neonates/young infants.

Antibiotic therapy (parenteral):

administer parenteral antibiotics in well-appearing febrile 8- 21 days old infants.

Antibiotic therapy (oral):

• Administer oral antibiotics in well-appearing febrile 29-60 days old infants if all of the following are met:CSF analysis, if obtained, is normalurinalysis is positiveall obtained inflammatory markers are normal.
• Discontinue parenteral antibiotics, if started, and initiate or continue oral antibiotic therapy in well-appearing febrile 29-60 days old infants with UTI managed at home if all of the following are met:urine culture is positiveall other bacterial cultures are negative at 24-36 hours

AAntibiotic therapy (discontinuation)::

Discontinue antibiotics in hospitalized 8-21 days old infants if all of the following are met:all culture results are negative at 24-36 hours or only positive for contaminantsthe infant continues to appear clinically well or is improving (such as fever, feeding)no other reasons for hospitalization.

4. Follow-up and surveillance

Hospital discharge criteria:

Discharge hospitalized 8-21 days old infants if all of the following are met:culture results are negative for 24-36 hours or only positive for contaminantsthe infant continues to appear clinically well or is improving (such as fever, feeding)no other reasons for hospitalization.

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