- Labs do not triage initial management of infants under 1 month or ill appearing children under 36 months
- All labs are performed in Fever Without Focus if under 1 month or ill appearing and under 36 months
- All infants with these risks are admitted and started on empiric Antibiotics
- Leukocytosis has poor Test Sensitivity of serious Bacterial Infection <60 days
- Cruz (2017) JAMA Pediatr 171(11):172927 [PubMed]
-
Blood Cultures
- Obtain in all febrile newborns age <30 days
- Avoid Blood Cultures in non-toxic febrile children without localizing symptoms >3 months of age
- Blood Cultures are more likely to be contaminated than true infection (RR 100x)
- See Fever Without Focus Management Birth to 3 Months
- CBC with differential
- Positive inflammatory marker if Absolute Neutrophil Count (ANC) >4000 cells/mm3
-
Procalcitonin (PCT)
- Positive inflammatory marker if >0.5 ng/ml
- When Procalcitonin is unavailable or pending, fever > 101.3 F (38.5 C) may be used as inflammatory marker
-
C-Reactive Protein (CRP)
- Positive inflammatory marker if >20 mg/L
-
Blood Culture (one set)
-
Urinalysis with microscopic exam
- Positive if any Leukocyte esterase present OR Urine White Blood Cells (WBC) >10 cells/mm3
-
Urine Culture
- Send in all febrile infants <=21 days or if positive Urinalysis
-
Lumbar Puncture
- Indications
- All ill appearing infants <60 days
- All febrile infants age <21 days old
- Febrile infants age 21 to 28 days old
- Optional in febrile infants age 29 to 60 days
- Positive criteria
- Any Neutrophils (PMNs) seen on grams stain OR
- White Blood Cells >18 cells in age <28 days (or >9 cells in age 29 to 60 days)
- Basic Metabolic Panel
- Indicated in age <21 days
- Total Serum Bilirubin
- Indicated in age <21 days
- Respiratory infection labs as indicated for respiratory symptoms (or at time of outbreak)
- Chest XRay
- Influenza Swab
- Covid19 nasal swab
- Respiratory Syncytial Virus (RSV) nasal swab
-
Herpes Simplex Virus (HSV)
- Indications
- HSV symptoms within 1 week of delivery
- Household HSV contact
- Vesicles
- Seizure
- Hypothermia
- Ill appearing infant
- Sepsis-like syndrome
- HSV Labs
- CSF Herpes Simplex Virus PCR
- Herpes Simplex Virus PCR and culture swabs from eye, Rectum (and Vesicle if present)
- Labs
-
Age 2 to 36 months AND signs of serious illness
-
Complete Blood Count (CBC) with differential
-
Blood Culture
-
Urinalysis and Urine Culture
- Age less than 24 months: Obtain both Urinalysis and Urine Culture
- Age 24 to 36 months: Consider Urinalysis and Urine Culture if urinary tract source is suspected
-
Lumbar Puncture for CSF Studies and culture
- Age 1 to 3 months: All ill appearing infants
- Age 3-36 months: Neurologic or meningeal signs present
-
Chest XRay Indications
- Respiratory symptoms
- Rectal Temperature > 102º F
- WBC >20,000
-
Stool Culture and Fecal Leukocytes Indications
- Diarrheal illness
- Labs
-
Age 2 to 36 months without signs of serious illness
- Consider Influenza test during Influenza season in ages 3 to 36 months
- Positive Influenza test often obviates need for further Fever Without Focus evaluation
-
Complete Blood Count (CBC) with differential
-
Blood Culture (draw and hold) when other labs obtained
-
Urinalysis and Urine Culture
- Age less than 24 months: Obtain both Urinalysis and Urine Culture
- Age 24 to 36 months: Consider Urinalysis and Urine Culture if urinary tract source is suspected
-
Lumbar Puncture for CSF Studies and culture
- Age <1 month: All febrile infants
- Age 1 to 3 months Indications
- All ill, toxic appearing infants
- Absolute Neutrophil Count >10,000/mm3
- CRP >20 ng/ml or Procalcitonin >0.5 ng/ml
- Mintegi (2017) Arch Dis Child 102(3): 244-9 [PubMed]
- Age 3-36 months Indications
- Altered Level of Consciousness or Neurologic signs
- Meningeal signs present
- Precaution
- Younger infants are less likely to demonstrate meningeal signs (Exercise caution)
- Normal WBC Count (between 5000 to 15000) does not rule-out Meningitis
- Bonsu (2003) Ann Emerg Med 41:206-14 [PubMed]
- Interpretation: Findings Suggestive of Bacterial Meningitis in Age <3 months
- CSF WBC >20/mm3
- CSF Protein >100 mg/dl
- CSF Glucose <20 ng/dl
- Leazer (2017) Pediatrics 139(5):e20163268 [PubMed]
-
Chest XRay Indications
- May avoid Chest XRay in Wheezing consistent with Asthma or Bronchiolitis
- Respiratory symptoms (respiratory distress, Tachypnea, pulmonary rales)
- Rectal Temperature > 102.2º F
- White Blood Cell Count >20,000
- Oxygen Saturation <95% (Hypoxia)
-
Stool Culture and Fecal Leukocytes Indications
- Diarrheal illness
- Indications
- Perform in all Fever Without Focus children age <24 months
- UTI is among the top two causes of serious Bacterial Infection under 36 months
- Rudinsky (2009) Acad Emerg Med 16(7): 585-90 [PubMed]
- Serious Urinary Tract Infections (Pyelonephritis, urosepsis) are increasing in Incidence
- Copp (2011) J Urol 186(3): 1028-34 [PubMed]
- Age <5 years AND 3 of the following criteria
- Pain or crying with urination
- Foul smelling urine
- Prior Urinary Tract Infection
- Severe Illness signs
- Absence of severe cough
- Ebell (2018) Am Fam Physician 97(4): 273-4 [PubMed]
- Clean catch, catheterized urine or suprapubic aspirate for all samples
- Bag urine has 85% False Positive Rate
- Bag urine may be used as reassuring if negative, but positive (LE, nitrite, pyuria) requires confirmation
- Fineell (2011) Pediatrics 128(3):e749-70 [PubMed]
-
Urine Culture all samples
- Urine dipstick False Negative Rate: 12%
- Gorelick (1999) Pediatrics 104(5): e54 [PubMed]
- Findings suggestive of Urinary Tract Infection
- Pyruia (>5 WBCs per HPF or >10 WBCs on enhanced Urinalysis)
- Urine Culture >50,000 CFU on urine catheterization or suprapubic sample
- Febrile UTI follow-up
- Age <2 years requires renal and Bladder Ultrasound (and if abnormal, VCUG)
- Labs
-
Infectious markers (age under 3 months)
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