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Febrile Infant: Lumbar Puncture Considerations

Clinicians may obtain a CSF analysis on infants 22 to 28 days of age even if all of the following criteria are met:

  1. Urinalysis result is negative or positive.
  2. Inflammatory Markers obtained are abnormal.
  3. Blood and urine cultures have been obtained.
  4. Infant is hospitalized.
  • LP is recommended before the administration of antimicrobial agents because interpreting CSF after the administration of antimicrobial agents is difficult.
  • However, the risk of meningitis in 22- to 28-day-old infants is lower than that in infants <22 days old in several studies.
  • Therefore, in some circumstances, clinicians may elect to defer an LP and initiate antimicrobial agents, recognizing the potential risk of partially treated meningitis.
  • Send CSF for cell count, Gram stain, glucose, protein, bacterial culture, and enterovirus PCR (if available) if pleocytosis is present and during periods of increased enterovirus prevalence.
  • HSV can occur in this age group. HSV should be considered 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.

Pantell, R. H., Roberts, K. B., Adams, W. G., Dreyer, B. P., Kuppermann, N., O’Leary, S. T., ... & Teichman, J. S. (2021). Evaluation and management of well-appearing febrile infants 8 to 60 days old.Pediatrics,148(2).

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.