Paediatric Pathways

INFANT <90 DAYS OF AGE WITH FEVER AND NO SOURCE PATHWAY FOR CHILDREN PRESENTING TO HOSPITAL FROM THE COMMUNITY

DIAGNOSIS

  • Temperature ≥38°C measured by axillary thermometer (in hospital or at home)
  • If within 24 – 48hrs of 8 week immunisations and appears well, consider period of observation +/- urinalysis if systemically well1,2

DIFFERENTIALS

  • Urinary tract infection (10 - 20%)
  • Bacteraemia (4%) including Group B Strep, E. coli etc.
  • Bacterial meningitis (0.5%)
  • Enterovirus/parechovirus infection/meningitis
  • Herpes simplex virus infection
  • Viral respiratory tract infections
  • Post-immunisation fever1,2

INVESTIGATIONS

  • FBC, CRP & blood culture
  • Urinalysis and MC&S (in out catheter preferred collection method because clean catch urine is associated with >25% contamination rate).3,4
  • Empirical lumbar puncture (LP) if <28 days1 or clinical concerns for bacterial meningitis – check for contraindications to LP
  • Only perform CXR or stool culture if indicated by clinical presentation.
  • Consider non-bacterial pathogens – tests may include nasopharyngeal swabs for respiratory viruses5, rectal swab for enterovirus and parechovirus. In babies under 4 weeks of age, consider neonatal HSV (collect eye/rectal/throat swabs +- blood +- CSF for HSV PCR)

ASSESSING SEVERITY

Low risk

  • >28 days of age and
  • Inflammatory markers not raised (CRP<20mg/L)9 and
  • Not unwell appearing and
  • Negative urinalysis10

MANAGEMENT

Low risk

  • Empirical antibiotics not necessary unless there are specific clinical concerns
  • Consider a period of observation to ensure the child remains well
  • Discharge with written safety net information

Moderate risk

  • Age >28 days and
  • Not unwell appearing and
  • either inflammatory markers raised (CRP≥20mg/L)9 and/or positive urinalysis

MANAGEMENT

Moderate risk

  • Treat with empirical IV antibiotics as per local/national guidelines whilst awaiting blood and urine cultures. Blood cultures can be reviewed at 24-36 hours (from time of loading onto machine)12,13 and considered alongside clinical progression, serial inflammatory markers and virology results to decide if Abs can be stopped as per principles of antimicrobial stewardship
  • If UTI diagnosed, see UTI pathway. Upper UTI not commonly associated with concomitant meningitis in babies >28 days of age11. LP not required (even if blood culture positive) unless ongoing clinical concerns about meningitis (persisting irritability)
  • Perform LP if positive blood culture (non-contaminant) in absence of focus of infection.
  • If the child remains clinically well after 4 hours, consider ambulating14 from ED or assessment unit with written safety net advice and clear plans for follow up if no social risk factors
  • Ensure robust clinical governance systems and documentation in place for children being ambulated
  • At 36-48 hours, review clinical progression, serial inflammatory markers, microbiology and virology results as per principles of antimicrobial stewardship.15 If low index of suspicious for invasive bacterial infection, stop Abs. If strong index of suspicion of invasive bacterial infection (i.e. markedly elevated CRP) and no alternative diagnosis, consider empirical 5 day IVAbx course.

If specific focus of infection confirmed, see written safety netting advice for duration of antibiotics and timing of step down from IV to oral therapy.

High risk

  • Infants ≤28 days of age or
  • Unwell appearing or
  • Comorbidities high risk for serious bacterial infection (immunosuppression, indwelling devices etc.)

MANAGEMENT

High risk

Full septic screen should be considered in any child ≤28 days with fever ≥38°C, unless contraindications for LP. Cultures should be sent prior to commencement of Abx although Abx should not be delayed in the unwell child. Treat with empirical IV antibiotics as per local/national guidelines whilst awaiting culture and sensitivities

  • If unwell looking, resuscitate according to APLS guidelines, treat with empirical IV antibiotics as per local / national guidelines (use early onset sepsis guidelines if age <72 hours). Perform an LP if no contraindications. Consider aciclovir if <28 days and requiring fluid boluses or CSF pleocytotis (if LP performed). Admit to hospital.
  • If UTI diagnosed, see UTI pathway. Upper UTI not commonly associated with concomitant meningitis in babies >28 days of age. Perform LP if confirmed UTI in baby <28 days or if clinical concerns (meningism / persisting irritability).
  • Perform LP if positive blood culture (non-contaminant) in absence of focus of infection.
  • If meningitis diagnosed, see meningitis pathway.

If the child is clinically well, consider ambulating with written safety netting advice and clear plans for follow up if no social risk factors**:
Ensure robust clinical governance systems and documentation in place for children being ambulated

  • At 36-48 hours, review clinical progression, serial inflammatory markers, microbiology and virology results as per principles of antimicrobial stewardship.15 If low index of suspicious for invasive bacterial infection, stop Abs. If no focus for infection found, and no alternative diagnosis, consider empirical treatment with 5 days of IVAbx if strong index of suspicion of invasive bacterial infection (i.e. markedly elevated CRP, unwell at presentation).

Other specific foci of infection (i.e. upper UTI, meningitis etc)

  • See relevant pathology specific guidelines for duration of antibiotics and timing of step down from IV to oral therapy.

The development of this pathway involved a systematic review of the literature, collaborative development of the pathway with relevant national groups followed by formal national consultation. For more information, click here

REFERENCES
  1. Campbell G, Bland RM, Hendry SJ. Fever after meningococcal B immunisation: A case series. J Paediatr Child Health 2019; 55: 932-7.
  2. Murdoch H, Wallace L, Bishop J et al. Risk of hospitalisation with fever following MenB vaccination: self-controlled case series analysis. Arch Dis Child 2017; 102: 894-8.
  3. Tosif S, Baker A, Oakley E et al. Contamination rates of different urine collection methods for the diagnosis of urinary tract infections in young children: an observational cohort study. J Paediatr Child Health 2012; 48: 659-64.
  4. Tzimenatos L, Mahajan P, Dayan PS et al. Accuracy of the Urinalysis for Urinary Tract Infections in Febrile Infants 60 Days and Younger. Pediatrics 2018; 141.
  5. Nicholson EG, Avadhanula V, Ferlic-Stark L et al. The Risk of Serious Bacterial Infection in Febrile Infants 0-90 Days of Life With a Respiratory Viral Infection. Pediatr Infect Dis J 2019; 38: 355-61.
  6. NICE (National Institute for Health and Care Excellence). Fever in under 5s: assessment and initial management. Clinical guideline [CG160]. Available at https://www.nice.org.uk/guidance/cg160/resources/fever-in-under-5s-assessment-and-initial-management-pdf-35109685049029. 2013.
  7. Martinez E, Mintegi S, Vilar B et al. Prevalence and predictors of bacterial meningitis in young infants with fever without a source. Pediatr Infect Dis J 2015; 34: 494-8.
  8. Mintegi S, Gomez B, Martinez-Virumbrales L et al. Outpatient management of selected young febrile infants without antibiotics. Arch Dis Child 2017; 102: 244-9.
  9. Gomez B, Mintegi S, Bressan S et al. Validation of the "Step-by-Step" Approach in the Management of Young Febrile Infants. Pediatrics 2016; 138.
  10. Kuppermann N, Dayan PS, Levine DA et al. A Clinical Prediction Rule to Identify Febrile Infants 60 Days and Younger at Low Risk for Serious Bacterial Infections. JAMA Pediatr 2019; 173: 342-51.
  11. Nugent J, Childers M, Singh-Miller N et al. Risk of Meningitis in Infants Aged 29 to 90 Days with Urinary Tract Infection: A Systematic Review and Meta-Analysis. J Pediatr 2019; 212: 102-10 e5.
  12. Theodosiou AA, Mashumba F, Flatt A. Excluding Clinically Significant Bacteremia by 24 Hours in Otherwise Well Febrile Children Younger Than 16 Years: A Study of More Than 50,000 Blood Cultures. Pediatr Infect Dis J 2019; 38: e203-e8.
  13. Biondi EA, Mischler M, Jerardi KE et al. Blood culture time to positivity in febrile infants with bacteremia. JAMA Pediatr 2014; 168: 844-9.
  14. Patel S, Abrahamson E, Goldring S et al. Good practice recommendations for paediatric outpatient parenteral antibiotic therapy (p-OPAT) in the UK: a consensus statement. J Antimicrob Chemother 2015; 70: 360-73.