Infectious Disease Book

Bacterial Infections

Febrile Illness

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Fever Without Focus Management 3 to 36 months

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  1. See Also
    1. Fever Without Focus
    2. Fever Without Focus Management Birth to 3 Months
  2. Indications
    1. Previously well child
    2. Febrile child 3 to 36 months without obvious source
  3. Triage
    1. Toxic appearing febrile child
      1. See Yale Observation Scale
      2. Admit to hospital
      3. Full rule-out Sepsis workup
      4. Parenteral antibiotics
    2. Non-toxic child with fever <39.0 C (<102.2 F)
      1. Avoid further diagnostic tests or antibiotics
      2. Fever Symptomatic Treatment
      3. Careful examination to rule out serious infection
        1. Pneumonia
        2. Abscess
        3. Cellulitis or Impetigo
        4. Acute Sinusitis
        5. Otitis Media
        6. Osteomyelitis
        7. Lymphadenitis
        8. Streptococcal Pharyngitis or Scarlet Fever
      4. Re-evaluation criteria
        1. Fever persists longer than 48 hours
        2. Condition deteriorates
    3. Non-toxic child with fever >38.9 C (>102.1 F)
      1. See protocol below
  4. Step 1: Evaluate Fever by rectal temperature
    1. Fever with rectal temperature <102.2 F (39 C)
      1. Observe without testing
      2. Follow-up if worsening or >48 hours of fever
    2. Fever with rectal temperature >102.2 F (39 C)
      1. Go to Step 2 unless criteria below met
      2. Criteria for observation without labs, antibiotics
        1. Non-toxic appearance
        2. Immunizations up-to-date
        3. Follow-up within 24-48 hours
  5. Step 2: Obtain Initial Labs
    1. Labs
      1. Complete Blood Count with differential
      2. Urinalysis with Urine Culture
    2. Protocol
      1. Go to step 3 unless criteria below are met
    3. Criteria for low-risk observation (24 hour follow-up)
      1. White Blood Cell count <15,000
      2. Absolute Neutrophil Count <10,000
      3. Urinalysis normal
  6. Step 3: Obtain Cultures
    1. Urine Culture
      1. Obtain in all cases
      2. Urinalysis alone is insufficient
    2. Blood Culture
      1. All cases in which labs abnormal above
      2. Obtain if antibiotics are given
    3. Cerebrospinal fluid (CSF) by Lumbar Puncture
      1. Usually not needed, unless Meningitis suspected
      2. Obtain if antibiotics are given
  7. Step 4: Additional Studies
    1. Chest XRay Indications
      1. Oxygen Saturation (O2 Sat) <95%
      2. Respiratory distress
      3. Tachypnea
      4. Rales on lung auscultation
      5. Fever 39.5 C (103.1 F) or higher
      6. Asymptomatic with White Blood Cell count >20,000
    2. Stool Culture Indications
      1. Stool blood or mucus present
      2. Fecal Leukocytes > 5 WBCs per high powered field
  8. Step 5: Consider Antibiotics (fever >39 C)
    1. Antibiotic coverage is optional
    2. Ceftriaxone (Rocephin) 50 mg/kg/day (max: 1 g)
    3. If antibiotics are given, then:
      1. Re-evaluate within 24 hours
      2. All cultures in Step 3 must be obtained
  9. Step 4: Instructions
    1. Follow-up
      1. Return within 24 hours if antibiotics started
      2. Return in 48 hours indication
        1. Fever persists
        2. Condition deteriorates
    2. Home management
      1. Observe for toxic appearance
      2. Fever Symptomatic Treatment
  10. Step 5: Blood Culture or Urine Culture positive
    1. Admit if child febrile or toxic appearance
    2. Outpatient antibiotics if afebrile and well-appearing
  11. References
    1. (1993) Ann Emerg Med 22(3):628
    2. Baraff (2000) Ann Emerg Med 36:602
    3. Baraff (1993) Pediatrics 92(1):1
    4. Daaleman (1996) Am Fam Physician 54(8):2503
    5. Kimmel (1996) Fam Pract Recert 18(7):69
    6. Luszczak (2001) Am Fam Physician 64(7):1219
    7. Lopez (1997) Postgrad Med 101(2):241
    8. Sur (2007) Am Fam Physician 75:1805

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