Febrile Infant: Ill Appearing Infant Workup and Treatment
Ill appearing infants require full evaluation for serious neonatal infections. We recommend obtaining the following studies and initiating empiric treatment:
- Diagnostic evaluation:
- CBC with differential, C reactive protein, basic metabolic panel, liver function tests
- Blood culture
- Urinalysis with micro with reflex to urine culture
- Lumbar puncture for CSF analysis:
- Cell counts
- Gram stain and bacterial culture
- Protein
- Glucose
- Enterovirus PCR (obtain in summer and fall or evidence of viral meningitis)
- HSV PCR (see below for HSV considerations.)
- HSV studies (if indicated, see below for HSV considerations):
- HSV blood PCR
- HSV CSF PCR
- HSV surface swabs for PCR (conjunctivae, nasopharynx, mouth, anus, and any cutaneous lesions)
- Other workups as clinically indicated
- Consider non-infectious etiologies
- Consider consultation with Infectious Diseases
- Empiric treatment (use meningitic dosing; see Lexicomp for dosing recommendations):
- Vancomycin AND
- Cefepime (Or if infant > 28 days old, ceftriaxone) AND
- Acyclovir (if indicated/obtaining HSV workup)
HSV considerations: HSV should be considered when there is a maternal history of genital HSV lesions or fevers from 48 hours before to 48 hours after delivery 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.
These pathways do not establish a standard of care to be followed in every case. It is recognized that each case is different, and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time. It is impossible to anticipate all possible situations that may exist and to prepare a pathway for each. Accordingly, these pathways should guide care with the understanding that departures from them may be required at times.