AAP 2021 Febrile Infant Guidelines

Well Appearing Overall Approach

0-28 Days

• Full sepsis w/u (including stool and CXR if symptoms)
• Empiric Abx
• Admission

29 – 56 or 60 days

• Can consider bronchiolitis and maybe influenza as a cause
• Probably still get UA/UCx even if bronchiolitis
• Risk stratification using Step-by-step or Rochester
• Needs LP if antibiotics

60 – 90 days

• Same general approach as 29 – 60 day olds but lower risk in this group particularly after vaccination
• All should probably get UA/UCx
• Can consider labs and BCx

3 mo – 3 yo

• Well appearing don’t need routine w/u
• Consider UA in well appearing based on risk factors as below
• Consider occult infection including bacteremia, UTI, PNA
• Medically fragile, premature, unimmunized are higher risk groups and likely need some w/u
• Fever long duration, high fever (>39 C) are higher risk for bacterial infection

Empiric Treatment

0-28 days

• Ampicillin (GBS, listeria, enterococcus)
• Cefotaxime or Gent (E coli)
• Consider Acyclovir (HSV)
• Consider Vancomycin (MRSA rf’s e.g. prolonged NICU stay)

29-60 days

• Ampicillin (up to 6 weeks for listeria, enterococcus etc)
• Cefotaxime or ceftriaxone (E coli, H flu, S pneumo)
• Consider vancomycin (especially on older end due to increasing S pneumo risk)
• Consider acyclovir

61-90 days

• Cefotaxime or ceftriaxone
• Vancomycin

Modified Step-By-Step

Criteria: Well-appearing and age 29-90 Days

• Start with UA – if positive needs w/u and abx/admission
• If UA neg – proceed to labs (Get BCx at same time) -> Procalcitonin if neg (<0.5 ng/ml) proceed
• CRP (neg is <20) or ANC (neg is <10K)
• If positive at any step no longer low risk -> obtain all cultures, abx, admit
• If all negative child is low risk and probably safe for discharge
• Caution if very recent onset of fever (≤ 2 h) – increases risk of false negative

Rochester Criteria

• Allows no LP in low risk cohort
• Many exclusions including prematurity
• Need CBC, Band count, UA and fecal leukocytes if significant diarrhea
• MD Calc link to score

Risk Statistics and Other

• Infants with bronchiolitis still ~ 4% prevalence of UTI
• RSV PCR (+) for up to a week after infection, rhinovirus for over a month

Simplified Algorithm