FEVER IN INFANTS LESS THAN 60 DAYS

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1 FEVER IN INFANTS LESS THAN 60 DAYS ALGORITHM Infant with Fever Rectal temperature 38 C r <36 C in clinic/ed r reliable histry f fever at hme? 28 days ld? r Clinical Suspicin f SBI? N N Fr reprt f tactile fever, yu can avid testing if 1 : N antipyretics meds were given Infant is well appearing Fllw up can be arranged in hrs Parents can measure rectal temp at hme Patient is nt high risk fr bacterial infectin: premature, maternal grup B strep, pr feeding, etc. Caregiver is cunseled n return precautins fr fever prir t discharge (Yu can bserve infant and measure temp if cncerned) Full Sepsis Wrkup CBC with diff r pint f care CBC Prcalcitnin (if available) LFTs (if suspected HSV) Bld cultures (x2) UA, urine culture (via cath) CSF (culture, cell cunt, prtein, glucse, meningitis encephalitis panel (MEP)) HSV labs and empiric acyclvir if high risk (see Page 2 fr HSV algrithm) Start empiric antimicrbials*: <28 days ld: ampicillin + gentamicin (If cncern fr meningitis, use ampicillin + ceftaxime) days ld: ceftriaxne (if cncern fr meningitis, add vancmycin) Inclusin Criteria Age 60 days Fever 38.0 C r < 36.0 C r reliable hx f fever at hme Parental reprt f tactile fever shuld be cnsidered Exclusin Criteria Current gestatinal age 37 weeks Current weight 2000 grams Need fr immediate critical care Chrnic r underlying illness Immuncmprmised Admit- see page 3 fr lcatin Narrw antimicrbial therapy based n culture results Nte: yu may cnsider admitting ff antibitics fr patients with negative UA, negative inflammatry markers, nrmal CSF, and t max <38.6 C Clinical Brnchilitis? N Prcalcitnin readily available? N UA, Urine Culture (via cath) CBC with diff r POC CBC Bld Cultures (x2) HSV labs and antimicrbials if high risk (see page 2 algrithm) Cnsider CSF (culture, cell cunt, prtein, glucse, meningitis encephalitis panel (MEP)) NO respiratry viral testing unless it will change management UA, Urine Culture Respiratry viral testing is generally NOT recmmended Cnsider: Flu PCR, bld culture, CBC Discharge/Admit as apprpriate (see page 3 fr admissin lcatin) Risk Stratificatin Prcalcitnin UA, urine culture (via cath) CBC with diff r pint f care CBC Bld cultures (x2) HSV labs and antimicrbials if high risk (see page 2 algrithm) NO respiratry viral testing unless it will change management See text fr acrnym definitins **High Risk fr SBI? *Additinal Antimicrbial Cnsideratins: If patient has clinical brnchilitis, cmplete full sepsis wrkup, but yu can admit and bserve ff antibitics If ceftaxime is unavailable, use ceftazidime If the tap is bldy r unable t btain LP, treat with meningitic dses (see table n page 6) while awaiting bld and urine cultures, see page 5 fr mre infrmatin If patient is high risk fr HSV (see page 2), add acyclvir N Prvider Discretin Discharge r Observe ff antibitics (see pg 3 fr admissin lcatins) If UA Ps (leuks/nitrites, WBCs >5), Negative PCT, & Temp <38.6 C- yu can discharge n ral antibitics after an initial parental antibitic dse (see pg 6 fr details) **High Risk fr SBI if any f the fllwing: 28 days ld Prcalcitnin: > 0.3ng/mL WBC <5,000 r >15,000/micrliter Abslute band cunt 1,500/micrliter CSF: psitive gram stain, >9 WBCs/mm 3 (29-60 days), r grssly bldy tap at any age (>10,000 RBCs/mm 3 ) See additinal high risk cnsideratins in text n page 5 Page 1 f 10

2 ALGORITHM- HSV Testing High Risk fr HSV? CSF plecytsis with a negative gram stain 1-28 days ld: >18 WBCs days ld: >9 WBCs Seizures Altered mental status Expsure t HSV lesins (including genital r skin/ral) Presence f vesicles Elevated ALT Leukpenia, thrmbcytpenia Hypthermia Ill appearing! Higher risk fr patients <21 days HSV Testing: MEP (r CSF HSV PCR*) HSV multisurce PCR (rder f cllectin: eye, naspharynx, muth, anus) (r culture if unavailable) Vesicle HSV PCR (if vesicle present) (r culture if unavailable) Bld HSV PCR CMP *If yu are nly suspicius f HSV (nt entervirus, parechvirus, r bacterial meningitis), cnsider HSV PCR testing instead f MEP. Empiric Treatment IV acyclvir IV Fluids at 1.5x maintenance Admit- see pg 3 Is CSF, multisurce, vesicle, AND bld HSV testing negative? N Cntinue IV acyclvir Cnsult Infectius disease Renal functin mnitring at after starting acyclvir Are yu still cncerned fr HSV (seizures, critically ill, etc.) Cntinue acyclvir Cntact ID N Stp acyclvir Page 2 f 10

3 ALGORITHM- Admissin Decisin t Admit Patient Requires ICU Resurces Advanced Airway Supprt (includes heated high-flw, apnea, seizures, etc.) Hemdynamic Instability Cncern fr bacterial meningitis (ie psitive CSF gram stain, CSF plecytsis) Prvider Cncern Age < 28 days r < 44 weeks gestatinal? N Requires ICU Resurces? N Admit t Flr/ Netwrk f Care (NOC) Inpatient Admit t PICU Requires ICU Resurces? Admit t NICU PICU (alternative if n beds available) N Admit t NICU based n Capacity Anschutz Campus- Call NICU first, patient shuld be admitted t NICU unless space prhibits. (this is t ensure flr bed availability fr patients >28days) Netwrk f Care (NOC)- admit t NOC inpatient if apprpriate r call NICU if there are any cncerns r n bed availability *Nte: Kaiser has the ptin f caring fr patients as an attending in the NICU r may request admissin t the flr nt the Kaiser service. Page 3 f 10

4 TABLE OF CONTENTS Algrithm Algrithm- HSV Testing Algrithm- Admissin Target Ppulatin Backgrund Definitins Initial Evaluatin Labratry Studies Imaging Therapeutics Dispsitin References Clinical Imprvement Team TARGET POPULATION Inclusin Criteria Age less than r equal t ( ) 60 days Fever (greater than r equal t (>) 38.0 C (100.4 F)) r less than (<) 36.0 C (96.8 F) Parental reprt f tactile fever shuld be cnsidered Gestatinal age greater than (>) 37 weeks AND weight greater than (> )2000 grams Exclusin Criteria Need fr immediate critical care Chrnic r underlying illness Immuncmprmised BACKGROUND DEFINITIONS Serius Bacterial Illness (SBI): Includes bacteremia/sepsis, meningitis, and urinary tract infectins (UTIs) Febrile infants less than 28 days are at higher risk f SBIs Fr febrile infants, n universal risk stratificatin currently exists t identify SBI either by clinical examinatin, rutine labratry tests, bimarkers r selectin criteria. 2,3 Rectal temperature crrelates mst clsely with cre bdy temperature 5 Infants with titis media are at the same risk f bacteremia as patients withut an titis media Infants with entervirus identified in cerebrspinal fluid (CSF) are lwer risk fr SBI, have decreased length f stay, expsure t antibitics, and hspital csts. 6,7,8,9 Page 4 f 10

5 Table 1: Incidence f SBI in infants 4 Incidence f infectin in febrile infants 7-90 days Urinary Tract Infectin (UTI) 17%** Bacteremia 2% Meningitis 0.9% **10% f patient with UTI will have bacteremia INITIAL EVALUATION Thrugh histry and physical examinatin including these high-risk cnsideratins: Maternal histry f intra-partum fever, antibitic treatment, grup B strep infectin Infant histry f prir antibitic treatment, hspitalizatin lnger than mther, previus hspitalizatin, unexplained hyperbilirubinemia, prematurity (less than 37 weeks), temp greater than 38.5 C 10 LABORATORY STUDIES IMAGING Prcalcitnin 11,12,13 Fr well-appearing infants days, a nrmal prcalcitnin lwers the risk f serius bacterial infectin. (Can cnsider discharge hme withut antibitics after bld and urine cultures are btained.) An elevated prcalcitnin warrants further investigatin fr serius bacterial infectin and antibitic initiatin while awaiting bld, urine, and CSF cultures. Traumatic/Dry Lumbar Punctures Interpretatin f traumatic r dry taps can be difficult. In general, traumatic lumbar punctures (LPs) are defined as greater than 500 RBCs/hpf and crrecting with ratis can be inaccurate. The decisin regarding whether r nt t treat fr meningitis in these situatins is influenced by degree f fever, degree f illness, ther labratry studies, cultures, age f the infant, and ther factrs. Nenatal Herpes Simplex Virus (HSV) 14,15 See algrithm n page 2 Early diagnsis and treatment imprves utcmes; untreated infectins ften result in death r serius mrbidity The vast majrity f nenatal HSV cases ccur in infants less than 28 days, with few cases reprted greater than 6 weeks f age Skin, eye, and mucus membrane infectin typically presents at 7-14 days f age, CNS infectin at days, and disseminated disease at 5-12 days Meningitis Encephalitis Panel (MEP) MEP rapidly tests CSF fr 14 cmmn causes f central nervus system (CNS) infectin but des nt rule ut meningitis due t ther pathgens. MEP shuld be rdered if cncern fr HSV and entervirus/parechvirus. If nly suspicius f a single rganism (r MEP unavailable), cnsider PCR testing fr individual rganism(s). Cnsider MEP fr entervirus and parechvirus testing regardless f CSF white bld cell cunt (WBC) (as mst lack plecytsis). Page 5 f 10

6 EMPIRIC THERAPY CLINICAL PATHWAY Viral Testing 13 Viral testing indicated in select infants based n seasn and clinical presentatin and nly if results will change management. Cnsider flu PCR during influenza seasn. Cnsider Gastrintestinal Pathgen Panel if bldy diarrhea. Additinal diagnstic studies if indicated: Basic metablic prfile (BMP) if cncern f dehydratin, electrlyte disturbance r if starting acyclvir THERAPEUTICS Antibitic Recmmendatins Obtain all cultures prir t antibitic administratin if pssible IV rute f antibitic administratin is preferred If entervirus r parechvirus is identified in a well-appearing infant, yu can discntinue antibitics Duratin f antibitic therapy varies based n diagnsis, culture results, and clinical imprvement f the infant Fcus Age less than r equal t 7 days Suspected ampicillin 50 mg/kg/dse UTI r SBI every 8 hurs, max 1000 mg/dse AND gentamicin 4 mg/kg every Suspected Meningitis r abnrmal CSF Suspected HSV 24 hurs ampicillin 100 mg/kg/dse every 8 hurs, max dse 2000 mg/dse AND ceftaxime 50 mg/kg/dse every 8 hurs, max 2000 mg/dse Age 8-28 days ampicillin 50 mg/kg/dse every 6 hurs, max 1000 mg/dse AND gentamicin 2.5 mg/kg every 12 hurs ampicillin 100 mg/kg/dse every 6 hurs, max 2000 mg/dse AND ceftaxime 50 mg/kg/dse every 6 hurs, max 2000 mg/dse Age days ceftriaxne 50 mg/kg/dse every 24 hurs, max 2000 mg/dse vancmycin mg/kg/dse IV every 6 hurs, max 1000 mg/dse AND ceftriaxne 100 mg/kg/dse every 24 hurs, max 2000 mg/dse acyclvir 20 mg/kg/dse IV every 8 hurs, max dse 1200mg Alternative t ceftaxime during medicatin shrtage fr infants less than r equal t 28 days ld: ceftazidime 50 mg/kg/dse every 8 hurs, max 2000 mg/dse Outpatient Antibitic Recmmendatins fr Urinary Tract Infectin (UTI) Fr nenates and infants less than 2 mnths f age with presumed UTI, initiate empiric parenteral antibitics. Nenates less than 1 mnth f age must receive parenteral therapy, due t inadequate drug absrptin, immature immune system and increased disseminatin f infectin 18. Bacteremia secndary t acute pyelnephritis ccurs in % f children less than 2 mnths f age 19. Page 6 f 10

7 Fr infants days ld with uncmplicated bacterial UTI and clse fllw-up, parenteral antibitics may be switched t ral antibitics at the discretin f the prvider after clinical imprvement. Oral antibitics shuld be chsen based n gram stain, culture results and lcal antibitic susceptibility patterns. Additinal Antibitic Cnsideratins days: Antibitics are nt indicated if labratry results are within nrmal limits, n cncern f SBI/sepsis, r high index suspicin f viral etilgy 20,13. Select site-specific treatment fr minr fcal infectin in wellappearing child DISPOSITION Admissin See Admissin Algrithm n page 3 Additinal cnsideratins fr admissin: Unable t cnfirm fllw up in less than 24 hurs Lack f telephne r transprtatin Inadequate hme resurces Caretaker unable t prvide care Ntify primary care prvider (PCP) and admitting physician Discharge Hme If the patient is diagnsed with a treatable infectin, then manage as apprpriate Discharge hme with gd fllw up if patient is well-appearing and cultures negative at hurs, wrkup fr age and appearance is cmplete and reassuring (including HSV if apprpriate). If well appearing infant greater than 7 days with entervirus r parechvirus identified, can discharge earlier Page 7 f 10

8 REFERENCES 1. Smitherman H, Macias C. Febrile infant (yunger than 90 days f age): Definitin f fever. January 3, Accessed December 19, Cuell Garcia CA, Tamez Gmez L, Valdez Ceballs J. [Ttal white bld cell cunt, erythrsedimentatin rate and C-reactive prtein fr the detectin f serius bacterial infectins in 0- t 90-day-ld infants with fever withut a surce]. An Pediatr (Barc) 2008;68: Gerdes JS. Diagnsis and management f bacterial infectins in the nenate. Pediatr Clin Nrth Am 2004;51:939-59, viii-ix. 4. Greenhw TL, Hung YY, Herz AM, et al. The changing epidemilgy f serius bacterial infectins in yung infants. Pediatr Infect Dis J 2014;33(6): Claudius I, Baraff LJ. Pediatric emergencies assciated with fever. Emerg Med Clin Nrth Am 2010;28:67-84, viiviii. 6. Byingtn, C. L., et al. (2004). "Serius bacterial infectins in febrile infants 1 t 90 days ld with and withut viral infectins." Pediatrics 113(6): King, R. L., et al. (2007). "Rutine cerebrspinal fluid entervirus plymerase chain reactin testing reduces hspitalizatin and antibitic use fr infants 90 days f age r yunger." Pediatrics 120(3): Dewan, M., et al. (2010). "Cerebrspinal fluid entervirus testing in infants 56 days r yunger." Arch Pediatr Adlesc Med 164(9): Wallace, S. S., et al. (2017). "Impact f Entervirus Testing n Resurce Use in Febrile Yung Infants: A Systematic Review." Hsp Pediatr 7(2): Pantell RH, Newman TB, Bernzweig J, Bergman DA, al e. Management and utcmes f care f fever in early infancy. Jama. 2004;291(10): Mintegi S, Gmez B, Martinez-Virumbrales L, Mrientes O, Benit J. Outpatient management f selected yung febrile infants withut antibitics. Arch Dis Child. 2017;102(3): di: Maniaci V, Dauber A, Weiss S, Nylen E, Becker KL, Bachur R. Prcalcitnin in yung febrile infants fr the detectin f serius bacterial infectins. Pediatrics. 2008;122(4):701-n/a. K, Faesch S, Gras-Le Guen C, et al. Use f Prcalcitnin Assays t Predict Serius Bacterial Infectin in Yung Febrile Infants. JAMA Pediatr 2016; 170: Caviness AC, Demmler GJ, Selwyn BJ. Clinical and labratry features f nenatal herpes simplex virus infectin: a case-cntrl study. Pediatr Infect Dis J 2008;27: Whitley R, Arvin A, Prber C, et al. Predictrs f mrbidity and mrtality in nenates with herpes simplex virus infectins. The Natinal Institute f Allergy and Infectius Diseases Cllabrative Antiviral Study Grup. N Engl J Med 1991;324: Levine DA, Platt SL, Dayan PS, Macias CG, al e. Risk f serius bacterial infectin in yung febrile infants with respiratry syncytial virus infectins. Pediatrics. 2004;113(6): Jantausch B, Kher KK. Clinical pediatric nephrlgy. In: Kher KK, Schnaper HW, Makker SP, Makker SP, editrs. Urinary tract infectin. 2nd ed. Lndn: Infrma Healthcare; pp Neuhaus TJ, Berger C, Buechner K, Parvex P, Bischff G, Getschel P, et al. Randmised trial f ral versus sequential intravenus/ral cephalsprins in children with pyelnephritis. Eur J Pediatr. 2008;167(9): Baker MD, Bell LM, Avner JR. The efficacy f rutine utpatient management withut antibitics f fever in selected infants. Pediatrics 1999;103: Management f infants and yung children with fever withut surce. Baraff LJ. Pediatr Ann Oct;37(10): Management f the Febrile Yung Infant: Update fr the 21st Century. Wll C, Neuman MI, Arnsn PL. Pediatr Emerg Care Nv;33(11): di: /PEC Page 8 f 10

9 CLINICAL IMPROVEMENT TEAM MEMBERS Sarah Schmidt, MD Emergency Medicine Kaitlin Widmer, MD Pediatric Hspitalist Lalit Bajaj, MD Emergency Medicine Leigh Anne Bakel, MD Pediatric Hspitalist Sharisse Arnld-Rehring, MD Kaiser Nicle Cliftn, MD Pediatric Resident Lee Engelbreath, MD Kaiser Jasn French, MD Pediatric Hspitalist James Gaensbauer, MD Infectius Disease Theresa Grver, MD Nenatal Intensivist Andrew Haynes, MD Infectius Disease, Fellw Satya Huin, MD Nenatal Intensivist Jni Mackenzie, PNP Emergency Medicine Kevin Messacar, MD Infectius Disease Rakesh Mistry, MD Emergency Medicine Sean O Leary, MD Infectius Disease Suchitra Ra, MD Infectius Disease Kathryn Rappaprt, MD EM, Fellw Emma Rss, PharmD NICU Pharmacist Irina Tpz, MD Emergency Medicine Amy Willis, MD Pediatric Hspitalist Julie Michie, MD Emergency Medicine Kaylee Wickstrm, RN, Prcess Imprvement Specialist Clinical Effectiveness APPROVED BY Clinical Care Guideline and Measures Review Cmmittee January 9 th, 2018 Pharmacy and Therapeutics Cmmittee February 1 st, 2018 MANUAL/DEPARTMENT ORIGINATION DATE Clinical Care Guidelines/Quality December 6, 2012 LAST DATE OF REVIEW OR REVISION February 1, 2018 APPROVED BY Lalit Bajaj, MD, MPH Medical Directr, Clinical Effectiveness REVIEW/REVISION SCHEDULE Scheduled fr full review n February 1, Clinical pathways are intended fr infrmatinal purpses nly. They are current at the date f publicatin and are reviewed n a regular basis t align with the best available evidence. Sme infrmatin and links may nt be available t external viewers. External viewers are encuraged t cnsult ther available surces if needed t cnfirm and supplement the cntent presented in the clinical pathways. Clinical pathways are nt intended t take the place f a physician s r ther health care prvider s advice, and is nt intended t diagnse, treat, cure r prevent any disease r ther medical cnditin. The infrmatin shuld nt be used in place f a visit, call, cnsultatin r advice f a physician r ther health care prvider. Furthermre, the infrmatin is prvided fr use slely at yur wn risk. CHCO accepts n liability fr the cntent, r fr the cnsequences f any actins taken n the basis f the infrmatin prvided. The infrmatin prvided t yu and the actins taken theref are prvided n an as is basis withut any warranty f any kind, express r implied, frm CHCO. CHCO declares n affiliatin, spnsrship, nr any partnerships with any listed rganizatin, r its respective directrs, fficers, emplyees, agents, cntractrs, affiliates, and representatives. Page 9 f 10

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