Evaluation and management of the low-risk, well-appearing febrile infant 29 to 60 days of age

IMs: inflammatory markers; SPA: suprapubic aspiration; LP: lumbar puncture; CSF: cerebrospinal fluid; KAS: key action statement; CRP: C-reactive protein; ANC: absolute neutrophil count; HSV: herpes simplex virus; PCR: polymerase chain reaction.

* Key action statement references are shown in parentheses. To see the statements, refer to the American Academy of Pediatrics Clinical Practice Guideline: Evaluation and management of well-appearing febrile infants 8 to 60 days old.

¶ If available, procalcitonin should be obtained along with ANC or CRP. If procalcitonin is unavailable, both ANC and CRP should be obtained, and a temperature >38.5°C is considered abnormal. IMs are considered abnormal at the following levels: (1) temperature >38.5°C, (2) procalcitonin >0.5 ng/mL, (3) CRP >20 mg/L, (4) ANC >4000 to 5200/mm³.

Δ Send CSF for cell count, Gram stain, glucose, protein, bacterial culture, and enterovirus PCR (if available) if CSF pleocytosis is present and during periods of increased local enterovirus prevalence. Although rare in this age group, HSV should be considered when there is a maternal history of genital HSV lesions and in infants with vesicles, seizures, hypothermia, mucous membrane ulcers, CSF pleocytosis in the absence of a positive Gram stain result, leukopenia, thrombocytopenia, or elevated alanine aminotransferase levels. For further discussion, see the current Red Book. Recommended HSV studies are CSF PCR; HSV surface swabs of mouth, nasopharynx, conjunctivae, and anus for HSV culture (if available) or PCR assay; alanine aminotransferase; and blood PCR. If CSF is unobtainable or uninterpretable, there are insufficient data to make a specific recommendation. Options include the following: observe without treatment for a period of time and, depending on infant clinical condition, repeat LP and/or laboratory markers; begin empirical antimicrobial agents and reassess in 24 hours on the basis of infant response and results of blood culture; if CSF is bloody or antimicrobial agents have previously been started, analysis by multiplex PCR can add additional information; consult with local a pediatric infectious disease specialist.

◊ Infant may be managed at home if parent and clinician agree that the following are present: reliable phone and transportation, parent willingness to observe and communicate changes in condition, and agreement to the infant being reevaluated in 24 hours.