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so let's break this down by age group
and here's how we will typically manage
infants who present with fever given
everything we've out like um to learn so
far if an infant is under 28 days and
that infant is febrile and well
appearing we're gonna get a urinalysis
and a urine culture we're gonna get a
CBC or maybe also a CRP and a
procalcitonin depending on your local
center and a blood culture and virtually
everyone will get a spinal tap
occasionally we might not get a spinal
tap if a child clearly has bronchiolitis
and we're afraid that the respiratory
stress is so severe it's hard to tap
them but generally we're gonna do our
best to get that spinal tap if there's
any abnormal labs then we're gonna treat
them but even if there's not abnormal
labs we're gonna admit them to the
hospital and we usually will give
antibiotics we might make exceptions in
a child who clearly has another source
of fever such as bronchiolitis and all
the labs are completely pristine if the
labs are abnormal or even if they're
normal most of the time we'll admit them
and we'll put them on antibiotics which
involve either ampicillin and gentamicin
or ampicillin and cefotaxime the
ampicillin is needed to treat group B
strep and Listeria although many people
are thinking Listeria is less common
than it used to be it still does
sometimes come around
remember ceftriaxone is not indicated in
children under 28 days of age because of
concerns of kernicterus we will now wash
them on antibiotics for a 24 to 36-hour
period gone are the days of the 48-hour
rule out we've now really limited this
to 24 or 36 hours and if all cultures
are negative we can send them home what
about a child between 4 weeks and 8
weeks of age in these children in this
age range of 29 to 60 days we see a
febrile infant we're going to get the
urine the urinalysis and those blood
tests
many centers are moving away from doing
a spinal tap in all of these patients
although it's a judgment call and
certainly if the child is sick appearing
I would get a spinal tap but I might
avoid it in a very well appearing chil
child especially one with dot
bronchiolitis or some other cause of
fever
if the urinalysis and the preliminary
studies of the blood the CBC the CRP are
the procalcitonin are abnormal then
we're gonna worry but if they're not
abnormal we can discharge the patient
home with close follow-up these patients
who are well appearing with fever who
have preliminary labs that are normal do
not necessarily need to come into the
hospital but if the labs are abnormal or
you're worried about the child or you
don't trust that they'll follow up we
will often admit them if we're admitting
them the decision about the LP is a
challenging one I certainly would not do
antibiotics unless I'd done the LP
because it's a nightmare when you've
already given the antibiotics and then
you decide you might need an LP because
that LP sterilizes within an hour of
giving the tap of giving the antibiotics
so we really want to avoid giving
antibiotics in a patient who hasn't yet
gotten an LP if the urinalysis is the
only positive lab and the LP is normal
we might consider discharge on oral
antibiotics especially if there's a low
rate of drug resistance in urinary tract
infection organisms in your community
that's a style decision and I would
leave that up to each individual
practitioner and each individual patient
now if only the CBC is abnormal you
could consider discharge on oral
antibiotics and closely watching at home
and then telling patients well you can
stop the antibiotics this is an
alternative that some people are
practicing it's not common if a child is
admitted we generally again we'll watch
for 24 to 36 hours and discharge if all
the cultures are negative let's finally
consider those children who are
for 61 days and up here's a febrile
infant were worried we're really outside
the realm of bacteremia and we're
certainly outside the realm of
meningitis the only thing we might need
to worry about is your an attract
infection in a child who has no other
source of fever so you'll get a UA
if it's normal they can go home if it's
abnormal they can still go home we can
treat most llúria tract infections with
oral antibiotics of course if the child
severe then we'll keep them in house but
if a child's well appearing with a fever
at this age they're usually okay to go
home so that's a brief summary as best I
can do of how we manage febrile infants
who present to the emergency room thanks
for your attention
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