Pediatric Residency Program: JAX



Evaluation and management of fever in the neonate and young infant (less than three months of age)AuthorsHannah F Smitherman, MDCharles G Macias, MD, MPHSection EditorsStephen J Teach, MD, MPHSheldon L Kaplan, MDDeputy EditorJames F Wiley, II, MD, MPHDisclosuresLast literature review version 19.2: May 2011 | This topic last updated: March 17, 2011 (More) INTRODUCTION?—?Although most neonates and young infants with fever have a benign viral illness, the goal of the evaluation is to identify those children who are at high risk for serious bacterial illness (eg, bacteremia, urinary tract infection, meningitis, bacterial gastroenteritis, pneumonia), and who therefore require empiric antimicrobial therapy and possibly hospitalization.The young febrile infant may demonstrate few, if any, interpretable clues to the underlying illness [1]. The limitations of the history and physical examination in neonates and young infants with fever traditionally have led to an aggressive laboratory evaluation, even for patients who were previously healthy, are well-appearing, and have no focal infection. In addition, most of the patients have been admitted to the hospital for antibiotic treatment pending negative cultures. This practice is expensive and can result in iatrogenic morbidity for a substantial number of infants [2].The evaluation of neonates and young infants younger than three months with fever is discussed below. The definition and etiology of fever in this age group, as well as traditional strategies for evaluating young infants with fever, are discussed elsewhere. (See "Definition and etiology of fever in neonates and infants (less than three months of age)"?and "Strategies for the evaluation of fever in neonates and infants (less than three months of age)".)The evaluation of infants and children age 3 to 36 months is discussed elsewhere. In addition, the diagnosis and treatment of specific infections, including meningitis, pneumonia, and urinary tract infections, is discussed elsewhere. (See "Fever without a source in children 3 to 36 months of age"?and "Clinical features and diagnosis of acute bacterial meningitis in children older than one month of age"?and "Clinical features and diagnosis of community-acquired pneumonia in children"?and "Urinary tract infections in newborns".)HISTORY?—?A thorough history is an essential component of the evaluation of all neonates and young infants with fever (T ≥38?C or 100.4?F). The history should address the following clues to the etiology of the fever:Associated symptoms (respiratory, gastrointestinal) and behaviors (feeding, irritability, activity) Exposures to sick contacts (siblings, babysitters, day care) Any previous illness, or antibiotic use Birth history, including perinatal factors that suggest an increased risk of vertically transmitted infection such as maternal fever; the mother's group B streptococcus status and prophylaxis; maternal history of sexually transmitted infections such as herpes simplex virus, gonorrhea, and chlamydia; prolonged rupture of membranes, and the infant's nursery course. (See "Management of the infant whose mother has received group B streptococcal chemoprophylaxis"?and "Neonatal herpes simplex virus infection: Management and prevention"?and "Neonatal herpes simplex virus infection: Clinical features and diagnosis", section on 'Epidemiology and transmission'.)PHYSICAL EXAMINATION?—?The physical examination must quickly identify the ill-appearing infant who requires immediate resuscitation and treatment. Specific finding to note are the following:Abnormal vital signs, including pulse oximetry, which may be a better predictor of pulmonary infection than respiratory rate [3,4] Toxic appearance including characteristics such as irritability, inconsolability, poor perfusion, poor tone, decreased activity, or lethargy Signs of localized infection such as omphalitis, arthritis, or limb swelling and inflammation, and skin lesions, including skin or mucus membrane lesions, consistent with a herpetic etiology Signs and symptoms associated with bacterial meningitis may be minimal or absent altogether. Subtle clues include altered sleep patterns, decreased oral intake, hyperthermia, hypothermia, or paradoxical irritability (infant more irritable when being held than when lying still). A bulging fontanelle classically presents late in the disease process. Other meningeal signs and symptoms gradually localize to the CNS only as the infant matures. Nuchal rigidity is present in only 27 percent of infants aged zero to six months with bacterial meningitis, compared with 95 percent of patients 19 months or older [5].LABORATORY TESTS?—?Studies that have included cohorts of infants younger than three months without an obvious source of fever on physical examination have used a variety of laboratory studies to identify infants at low risk of serious bacterial infection (SBI) [6-15].WBC count?—?The white blood cell (WBC) count has been a standard part of the evaluation in virtually all studies of fever in young infants. In most studies, low-risk criteria included a WBC count <15,000/microL, although in one study, low risk was defined as WBC count <20,000/microL [9], and in another, 5000 to 15,000/microL [11]. The number of bands on differential should be no higher than 1.5 x 10(9) cells/L (1500/microL) [11]. (See "Strategies for the evaluation of fever in neonates and infants (less than three months of age)".)Despite its common use, observational studies report that WBC count has poor sensitivity and specificity for identifying bacteremia and meningitis in young infants [16,17]. For this reason, we suggest that the decision to perform a blood culture or a lumbar puncture not be based solely on the WBC count.Inflammatory mediators?—?Preliminary evidence from small single center observational studies suggests that elevation of procalcitonin level may be a better marker of SBI than WBC in febrile infants [18,19].An observational study of 234 young infants found that a cutoff value for procalcitonin of 0.12 nanograms/mL had a sensitivity of 95 percent (95% CI 83-99 percent), a specificity of 26 percent (95% CI 20-32 percent), and a negative predictive value of 96 percent (95% CI 85-99 percent) for serious bacterial illness [18]. An observational study of 271 young infants found that young infants with SBI and immunized febrile young infants had higher median procalcitonin levels than unimmunized febrile young infants without serious bacterial infection (0.53, 0.29, and 0.17 nanograms/mL, respectively). In this study, a cut off value of 0.12 nanograms/mL had a sensitivity of 96 percent (95% CI 83-99 percent), a specificity of 23 percent (95% CI 18-29 percent), and a negative predictive value of 96 percent (95% CI 86-99 percent) for detecting serious bacterial infection [19].In most clinical settings, PCT has limited availability. In addition, questions exist regarding the reliability of the bedside procalcitonin assay used in these studies because of variation in results by age, type of infection, and pathogen [20]. Further study is needed to better define the utility of procalcitonin for identifying febrile young infants (under 90 days of age) with serious bacterial infection.Data concerning C-reactive protein in febrile infants (less than 90 days) is more limited. (See "Fever without a source in children 3 to 36 months of age", section on 'Inflammatory mediators'.)Urine examination?—?We recommend that a urinalysis and urine culture be obtained because the incidence of urinary tract infection (UTI) is high among febrile young infants [11,21,22]. (See "Epidemiology and risk factors for urinary tract infections in children".)A negative urine dipstick or urinalysis alone does not exclude UTI; pyuria is absent on initial urinalysis in up to 20 percent of febrile infants with pyelonephritis [23]. Thus, urine culture should be performed on all specimens.A urine specimen for culture should be obtained by urethral catheterization or suprapubic aspiration, as bag collections frequently are contaminated [24]. (See "Urinary tract infections in newborns", section on 'Urine collection'?and "Urine collection techniques in children".)Stool examination?—?Not all studies of febrile neonates and young infants included evaluation of the stool for WBCs in patients with diarrhea. One study found the presence of ≥5 WBCs per high-power field to be a predictor of occult Salmonella infection, including bacteremia [11]. However, a Wright stain of the stool for WBCs may not be readily available. A stool culture is suggested when there is blood and/or mucus in the stool, or for the infant with diarrhea when a Wright stain is not available.Lumbar puncture?—?We recommend that lumbar puncture always be performed in febrile infants with the following indications (see 'Evaluation and management'?below):Age ≤28 days Ill appearance Diagnostic evaluation identifies a high risk for bacterial infection (see "Strategies for the evaluation of fever in neonates and infants (less than three months of age)") Prior to administration of empiric antibiotics Clinically evident invasive infection (eg, cellulitis, abscess, mastitis, omphalitis, osteomyelitis) (see "Evaluation and management of suspected methicillin-resistant Staphylococcus aureus skin and soft tissue infections in children", section on 'Severe SSTI') SeizuresThe cerebrospinal fluid should be sent for cell count, glucose, protein, and bacterial culture. In addition, viral studies (viral culture, polymerase chain reaction [PCR]) should be sent if the clinical picture suggests viral meningitis (table 1). (See "Viral meningitis: Clinical features and diagnosis in children", section on 'CSF studies'.)Several observational studies suggest that infants at low risk of SBI can be identified without performing a lumbar puncture [6,7,11,13,14]. Based on these reports, some consider lumbar puncture optional in a generally well-appearing infant who is over 28 days of age, particularly if the infant has a low-grade fever [21].However, the significant morbidity and mortality associated with bacterial meningitis may outweigh the low incidence of this infection in making the decision whether or not to perform a lumbar puncture. (See "Strategies for the evaluation of fever in neonates and infants (less than three months of age)".)We recommend that lumbar puncture be performed if empiric antibiotics are prescribed [3]. Otherwise, if the child returns for further evaluation and lumbar puncture at that time reveals CSF pleocytosis, it will not be clear whether a negative culture result is due to partially treated bacterial meningitis or aseptic meningitis. This uncertainty may result in the infant receiving an unnecessary course of antibiotics.Seizures may be a sign of meningitis, and we recommend that a lumbar puncture be performed in all neonates and young infants who have had a seizure. Appropriate CSF studies to identify possible viral etiologies may be useful diagnostically (table 1). (See "Viral meningitis: Clinical features and diagnosis in children", section on 'Virology'.)Blood culture?—?Blood culture does not help with the immediate assessment of fever but should be obtained routinely in the infant <28 days old or in older infants prescribed empiric antibiotics. Rapid detection of bacterial pathogens is possible with automated blood culture techniques, allowing the identification of positive culture results often within 24 hours. This is particularly helpful in infants managed as outpatients [3].Chest radiograph?—?Not all studies of febrile neonates and young infants have included a chest radiograph as part of the initial evaluation. A chest radiograph is helpful in identifying a source of infection in infants with at least one clinical sign of pulmonary disease [24]. This was illustrated in a meta-analysis of 617 febrile infants under three months of age [25]. All 361 infants who had no clinical evidence of pulmonary disease (defined as respiratory rate >50 breaths/min, rales, rhonchi, retractions, wheezing, coryza, grunting, stridor, nasal flaring, or cough) had normal chest radiographs. In contrast, 85 of 256 infants (33 percent) with at least one of these signs had an abnormal chest radiograph.Even when the chest radiograph reveals pneumonia, a viral etiology is most likely, given that nonbacterial pneumonias comprise the majority of cases of pneumonia in children [26]. A bacterial process is more likely if alveolar disease (consolidation and air bronchograms) or bronchopneumonia (diffuse bilateral pattern with increased peribronchial markings and small fluffy infiltrates) is present.EVALUATION AND MANAGEMENT?—?A cautious approach to neonates (0 to 28 days) and young infants (29 to 90 days) with fever is prudent, given the risk and potentially adverse consequences of unrecognized and/or untreated serious bacterial infection (SBI). Multiple approaches to the evaluation of these infants, with varying inclusion and exclusion criteria, have been proposed and studied, including protocols from Boston, Philadelphia, and Rochester [9-11]. While these approaches have a high negative predictive value (ability to remove patients with SBI from the low-risk group), each suffers from a relatively low positive predictive value, resulting in many infants undergoing unnecessary laboratory testing, hospitalization, and exposure to unnecessary antibiotics. (See "Strategies for the evaluation of fever in neonates and infants (less than three months of age)".)The predictors of SBI used to classify febrile infants into risk subsets aid in the assessment of risk, but they do not eliminate risk. There is a lack of definitive data to guide patient evaluation, and some categories that define high-risk groups such as age and white blood cell (WBC) count are arbitrary. Consequently, each patient and each clinical situation must be evaluated individually. (See "Strategies for the evaluation of fever in neonates and infants (less than three months of age)".)Neonates (0 to 28 days)?—?The available guidelines and approaches to fever in young infants do not perform well in neonates 28 days of age and younger compared with older infants [1]. Consequently, most experts recommend that all neonates with a rectal temperature ≥38?C have blood, urine, and CSF cultures performed regardless of clinical appearance [27,28]. A chest radiograph should be obtained in those with any sign or symptom of pulmonary disease. These neonates should be admitted to the hospital and treated presumptively with antibiotics (table 2). (See "Strategies for the evaluation of fever in neonates and infants (less than three months of age)", section on 'Limitations in neonates'.)Antibiotic therapy?—?Serious bacterial illness is present in 12 percent of febrile neonates [29]. Group B Streptococcus, a common pathogen in this age group, causes high rates of meningitis (39 percent) and sepsis (9 percent). Prior to routine antibiotic administration to intrapartum mothers and to febrile neonates, the case fatality rate approached 50 percent in babies with early onset group B Streptococcal infection [30]. Other organisms that cause SBI in neonates include Escherichia coli and other gram negative rods, enterococcus. and Listeria monocytogenes [31,32]. In addition, Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis cause disease in the slightly older neonate.Because of the high rates of serious bacterial infection and high risk of mortality if untreated, we recommend empiric treatment with antibiotics. Ampicillin?and gentamicin?or ampicillin and cefotaxime?will provide empiric coverage for these organisms until culture results are available (table 2). (See "Definition and etiology of fever in neonates and infants (less than three months of age)".)Acyclovir?—?Although acyclovir?should not be used routinely in the management of febrile neonates, those who are ill-appearing, have mucocutaneous vesicles, or have seizures should be treated with acyclovir (60 mg/kg per day divided three times daily). In addition, elevated liver enzymes may be an early indicator of disseminated HSV in neonates less than two weeks of age. Controversy exists regarding the use of empiric acyclovir in neonates who have CSF pleocytosis without other clinical features suggestive of HSV. We suggest that such patients receive acyclovir empirically pending the results of bacterial CSF culture and CSF HSV DNA polymerase chain reaction (PCR). (See "Neonatal herpes simplex virus infection: Management and prevention"?and "Neonatal herpes simplex virus infection: Clinical features and diagnosis", section on 'Clinical manifestations'.)Cultures of skin vesicles (if present), oropharynx, conjunctivae, urine, blood, stool, and CSF for HSV should be obtained before the initiation of acyclovir. HSV antigen may be detected using direct fluorescent antibody tests of scrapings from the base of vesicles. In addition, CSF should be sent for HSV DNA PCR. (See "Definition and etiology of fever in neonates and infants (less than three months of age)".)Ill-appearing infants (29 to 90 days)?—?Infants who are ill-appearing, have an abnormal cry, or temperatures ≥38.5?C have a higher risk of SBI [33,34]. Because up to 45 percent of ill-appearing young infants may have SBI [1], such infants should undergo the following treatment:Full laboratory evaluation including blood, urine, and CSF Chest radiograph if signs or symptoms of pulmonary disease are present (respiratory rate >50 breaths/min, rales, rhonchi, retractions, wheezing, coryza, grunting, stridor, nasal flaring, or cough). Empiric antibiotic therapy (with cefotaxime?or ceftriaxone), regardless of the initial laboratory results. Empiric therapy should also be adjusted based on specific clinical findings as follows:Vancomycin?should be given to those infants with evidence of soft tissue infection. (See "Evaluation and management of suspected methicillin-resistant Staphylococcus aureus skin and soft tissue infections in children", section on 'Severe SSTI'.) Vancomycin?should be given to those infants with CSF pleocytosis to treat meningitis caused by S. pneumoniae that is not susceptible to cefotaxime?or ceftriaxone?and, in infants 29 to 60 days of age, ampicillin?should also be given to cover Listeria monocytogenes (table 2). (See "Treatment, prognosis, and prevention of Listeria monocytogenes infection".)Hospital admissionWell-appearing infants29 to 60 days?—?For well-appearing infants with a temperature ≥38.0?C, laboratory testing is necessary to determine which patients are at high risk for an SBI [11]. A complete history and physical examination with appropriate laboratory evaluation including CBC, blood culture, urinalysis and culture, and CSF for cell count and culture should be performed in most patients. Infants without CSF pleocytosis, a WBC count 5000 to 15,000/microL, and a normal urinalysis are at low risk for an SBI.Some clinicians may elect to perform fewer laboratory tests. There are, however, no guidelines for the minimal evaluation of fever in well-appearing infants ages 29 to 60 days. The following factors should be considered:Urinary tract infections (UTIs) are common in this age group, particularly in uncircumcised boys and in girls [22]. Consideration always should be given to performing a urinalysis with culture. A WBC count 5000 to 15,000/microL with less than 1500 bands/microL suggests a lower risk of SBI. A stool culture should be performed if diarrhea is present. Lumbar puncture may not be necessary in some well-appearing infants who have knowledgeable caregivers, transportation, and well-established follow-up. However, a lumbar puncture should always be performed whenever empiric antibiotics are prescribed. A chest radiograph should be obtained in infants with at least one clinical sign of pulmonary disease (respiratory rate >50 breaths/min, rales, rhonchi, retractions, wheezing, coryza, grunting, stridor, nasal flaring, or cough) [25,35].Infants 29 to 60 days of age with CSF pleocytosis or a peripheral WBC ≥20,000/microL should be admitted to the hospital for treatment with empiric parenteral antibiotics. Many clinicians may also prefer to admit infants with WBC ≤5000/microL and WBC ≥15,000/microL. We also suggest that those with an abnormal urinalysis be treated with parenteral antibiotics as inpatients. (See "Strategies for the evaluation of fever in neonates and infants (less than three months of age)".)However, some experts treat well-appearing infants with an abnormal urinalysis with parenteral antibiotics as outpatients [36]. Limited data from a retrospective review of the hospital course of febrile infants <60 days of age with UTI demonstrated that progression of illness was unlikely and lends some support to this strategy [37].Multiple prospective studies have reported that infants who are at low risk of SBI based on history, physical examination, and whatever laboratory testing has been performed can be safely managed as outpatients. Reliable follow-up must be arranged within 24 hours (either by phone or by return visit to the clinician). If the social situation suggests that follow-up within 24 hours is problematic (eg, transportation problems or other concerns regarding parental adherence), then the infant should be admitted to the hospital. (See "Strategies for the evaluation of fever in neonates and infants (less than three months of age)", section on 'Traditional strategies'.)Infants who are followed as outpatients may be treated presumptively with ceftriaxone?(50 mg/kg in a single dose), pending culture results. In making the decision whether or not to prescribe empiric antibiotic therapy, the clinician must consider both the potentially severe risk of not treating an SBI as well as the more common but typically less severe risks associated with parenteral antibiotic administration. We suggest that CSF be obtained if antibiotics are given empirically.61 to 90 days?—?Data regarding the incidence of serious bacterial infection (SBI) among infants 61 to 90 days of age with fever (as compared with younger infants) on which to base definitive guidelines are limited. The risk of SBI for this age group may be similar to that for older febrile infants. In a prospective observational study (conducted after the initiation of routine immunization of infants with conjugated pneumococcal vaccine) describing febrile infants 57 to 180 days of age, there was no significant difference in the incidence of SBI between those who were 57 to 89 days of age and those who were older [38]. (See "Fever without a source in children 3 to 36 months of age".)Since infants less than three months of age have not yet been fully immunized against pneumococcus and Haemophilus influenzae type b, most experts recommend a CBC, urinalysis, and cultures of blood and urine be obtained in those who are well-appearing. (See "Fever without a source in children 3 to 36 months of age", section on 'Well-appearing'.)Those who have signs of pulmonary disease should have a chest radiograph as well.Despite its poor ability to identify young infants with bacteremia or meningitis, a WBC outside of the normal range of 5000 to 15,000/microL suggests the need for lumbar puncture followed by treatment with parenteral antibiotics until all cultures are final (table 2). For outpatient therapy in patients with normal CSF and urinalysis, ceftriaxone?(50 mg/kg) is the preferred drug because of its antimicrobial spectrum and long duration of action (see 'WBC count'?above).Infants with an abnormal urinalysis should receive parenteral antibiotics. Some experts suggest that these infants be admitted to the hospital, regardless of clinical appearance. (See "Acute management, imaging, and prognosis of urinary tract infections in children".)As with infants 29 to 60 days of age, the clinician must consider the risk of not treating an SBI as well as the risks associated with parenteral antibiotic administration in deciding whether or not to prescribe empiric antibiotic therapy ( HYPERLINK "" ceftriaxone?50 mg/kg in a single dose). We suggest that CSF be obtained if empiric antibiotics are prescribed (see 'Lumbar puncture'?above).Follow-up for outpatient treatment?—?Well-appearing infants ages 29 to 90 days who are sent home must have follow-up within 24 hours either by phone or by visit, at which time preliminary culture results (if obtained) are reviewed. Patients who received parenteral antibiotics at the initial visit should return for a second intramuscular dose (eg, ceftriaxone?50 mg/kg) pending final culture results.Any of the following circumstances warrants extensive evaluation and hospitalization for empiric antibiotic therapy with cefotaxime, ceftriaxone, or other antibiotics, as indicated:Any deterioration in clinical status or worsening of fever A positive blood culture not thought to be a contaminant A positive urine culture in an infant who remains febrileFor an infant with a positive urine culture who is afebrile and well-appearing less than 24 hours after parenteral ceftriaxone, it may be reasonable to give a second dose of parenteral ceftriaxone at 24 hours and continue outpatient follow-up. (See "Urinary tract infections in newborns".)Discharge criteria for admitted patients?—?Neonates and young infants who remain well-appearing or who rapidly improve may either be treated with or observed off antibiotics while in the hospital, until bacterial cultures have been negative for 24 to 48 hours.The length of hospitalization depends on the type of culture system in use. For example, continuously monitored blood culture instruments identify between 77 and 87 percent of all cultures with pathogens [39,40]?and 95 percent of critical pathogens (eg, S. pneumoniae, Salmonella and other Enterobacteriaceae, N. meningitidis, groups A and B streptococcus) within 24 hours [39]. Patients sent home before cultures have been negative for 48 hours must have follow up within 24 hours either by phone or by visit, at which time preliminary culture results are reviewed. If antibiotics were given in the hospital, then the child should receive two additional doses of antibiotics (eg, ceftriaxone?50 mg/kg daily) until all cultures are final and negative.Initial treatment with acyclovir?implies significant clinical concern for herpes infection. It would seem prudent then to continue to treat the infant with acyclovir until the PCR result of CSF specimen is available. (See "Neonatal herpes simplex virus infection: Management and prevention".)Fever may persist after cultures are negative at 48 hours. For the patient whose clinical condition has improved, a period of observation in the hospital off antimicrobial therapy would be reasonable. The child who remains ill or who does not improve as expected should be carefully reevaluated, and further testing, consultation, and treatment options should be pursued.DIFFICULT CLINICAL SITUATIONS?—?Some clinical situations arise that do not fit neatly into treatment guidelines. Until more definitive information becomes available, these circumstances should be considered on an individual basis, using clinical judgment.Dry lumbar puncture?—?When the decision is made to perform lumbar puncture, every reasonable attempt should be made to obtain CSF. However, this cannot always be accomplished. In this circumstance, cultures of blood and urine should be obtained. Infants 28 days of age or younger should be admitted to the hospital and treated with meningitic doses of antibiotics pending those results.Negative blood and urine culture results in a baby who does well would be reassuring, although the true incidence of meningitis in patients who have negative blood and urine cultures is not known. In addition, a brief period of inpatient observation off of antibiotics could be considered.On the other hand, a repeat lumbar puncture should be performed to obtain CSF if either the blood or urine culture is positive. The finding of CSF pleocytosis would necessitate a prolonged course of parenteral antibiotics. (See "Clinical features and diagnosis of acute bacterial meningitis in children older than one month of age"?and "Treatment and prognosis of acute bacterial meningitis in children older than one month of age", section on 'Duration of therapy'.)For an infant 29 days or older in this situation, a similar approach is sensible. However, the young infant in this age group who does well and has negative blood and urine cultures probably does not need an inpatient observation period off antibiotics.Traumatic lumbar puncture?—?A traumatic lumbar puncture is not unusual in young infants. The tube in which the CSF is clearest should be sent for the cell count. The interpretation of results from traumatic lumbar puncture is discussed elsewhere. (See "Lumbar puncture: Indications, contraindications, technique, and complications in children"?and "Cerebrospinal fluid: Physiology and utility of an examination in disease states".)The possibility of meningitis cannot be excluded when the CSF cell count is uninterpretable. In this situation, the infant should be treated with meningitic doses of antibiotics until the CSF culture is negative at 48 hours. A repeat lumbar puncture after admission, or observing the infant in the hospital off antibiotics after the cultures are negative at 48 hours, may be helpful when there is uncertainty regarding the possibility of meningitis. The infant who has done well and has negative CSF cultures at 48 hours may not require a repeat lumbar puncture.When the CSF culture is negative and a pathogen grows from the blood or urine, a normal CSF white blood cell (WBC) count would be reassuring in the child who has persistent fever or is not well-appearing.Patient on antibiotics?—?A young infant on prophylactic antibiotics, usually for a urinary tract abnormality, may have a serious bacterial illness masked by negative culture results. CBC, UA, CSF cell count, and cultures of blood, urine, and CSF should be obtained with the understanding that regardless of the laboratory evaluation, these patients cannot be classified as "low risk" for serious bacterial infection (SBI), since they have an underlying condition that places them at risk for SBI. Neonates should be admitted to the hospital and treated empirically with ampicillin?and gentamicin?or ampicillin and cefotaxime, at least until cultures have been negative for 48 hours. For well-appearing infants ≥29 days, it would be reasonable to consider admission to the hospital and empiric antibiotic therapy, or at least observation in the hospital off of antibiotics.Concomitant viral infections?—?Despite the concern for SBI, most young infants with fever have a viral illness. The presence of upper respiratory symptoms does not rule in a viral etiology, nor conversely rule out an SBI. However, infants with a "recognizable viral syndrome," such as bronchiolitis, croup, varicella, or stomatitis, have a markedly lower risk for bacteremia, although UTI remains a significant concomitant infection in those with bronchiolitis and influenza [41,42].Influenza?—?Rapid diagnostic tests for the detection of viral neuraminidase are commercially available for influenza A and B viruses and can be used for rapid point of care testing. However, test performance is variable. False positive results occur and are of particular concern if rapid influenza testing is used to limit further laboratory evaluation in young febrile infants. As a result, rapid influenza testing should only be relied upon for clinical management during the time of regional high prevalence for influenza infection, since high prevalence will raise the positive predictive value. (See "Clinical features and diagnosis of influenza in children", section on 'Laboratory diagnosis'.)In a multicenter trial of 844 febrile infants ≤60 days of age who were tested for influenza, a significantly lower rate of serious bacterial illness (SBI) was noted in the 123 infants who were influenza-positive compared with the 721 infants who were influenza-negative (2.5 percent versus 11.7 percent, relative risk 0.19 [95% CI 0.06-0.59]) [43]. The three infants with SBI in the influenza-positive group all had a urinary tract infection (UTI); none had bacteremia or meningitis. In contrast, SBIs in influenza-negative patients included 77 with UTIs, 16 with bacteremia, and 6 with meningitis.Although bacteremia was not identified in any of the 123 febrile infants with influenza, we suggest that a complete blood count (CBC) with differential, blood culture, urinalysis, urine culture, and, in children with clinical signs of pneumonia, a chest radiograph be obtained. If the CBC and urinalysis do not suggest bacterial infection, lumbar puncture can be omitted in well-appearing febrile infants who are older than 28 days of age, have a positive rapid influenza test, and no evidence of bacterial infection on physical examination. This approach should only be considered if the rapid influenza test in use has high specificity and is obtained during a time of high prevalence of influenza infection in the region, thereby maximizing the positive predictive value.Parents of infants more than 28 days of age who are discharged home from the emergency department should understand that worsening respiratory distress, ill appearance, or inability to feed warrant emergent return for medical care. In addition, these patients should have assured follow-up with their primary care provider within 24 hours for possible worsening disease. As an example, rapidly progressive Staphylococcus aureus pneumonia has been described in infants and children with influenza and should be suspected if other members of the family have had or have S. aureus infection. (See "Clinical features and diagnosis of influenza in children", section on 'Bacterial coinfection'?and "Epidemiology and clinical spectrum of methicillin-resistant Staphylococcus aureus infections in children".)Current evidence is insufficient to identify the risk of SBI in febrile neonates ≤28 days of age with influenza infection, as only 36 such patients were in the above trial [43]. Extrapolation from studies of febrile neonates with concomitant RSV infection suggest that those with influenza infection may remain at high risk for an SBI and should undergo a full evaluation followed by inpatient observation with antibiotic therapy. (See 'Bronchiolitis'?below.)Bronchiolitis?—?Multiple retrospective and prospective observational studies demonstrate that the incidence of SBI is 1.1 to 7 percent among febrile infants with bronchiolitis as opposed to 10 to 17 percent in high risk febrile infants without bronchiolitis [41,44-53]. However, the risk of SBI among neonates (0 to 28 days of age) is substantial and was not altered by the presence of RSV infection in one large prospective multicenter observational study [41].UTI is the most common SBI seen in febrile infants with bronchiolitis. Bacteremia may be found in up to 1 percent of these patients [41]. No cases of meningitis have been described in febrile infants with concomitant clinical bronchiolitis.These findings suggest that it may be reasonable to limit laboratory testing in well-appearing febrile infants older than 28 days of age with bronchiolitis to CBC, blood culture, urinalysis, and urine culture. If the CBC and urinalysis do not suggest bacterial infection, then these children may be managed without antibiotics according to the degree of illness caused by their bronchiolitis. (See "Bronchiolitis in infants and children: Treatment; outcome; and prevention", section on 'Indications for hospitalization'.)Febrile neonates (0 to 28 days) with bronchiolitis remain at high risk for an SBI and should have a full evaluation and inpatient observation with antibiotic therapy.Otitis media?—?Acute otitis media (AOM) is diagnosed infrequently in neonates and young infants. Nevertheless, the infant who presents with otitis media, with or without fever, can present a diagnostic and management challenge. (See "Acute otitis media in children: Epidemiology, microbiology, clinical manifestations, and complications"?and "Acute otitis media in children: Diagnosis".)The Rochester [11]?and Boston criteria [9]?specifically exclude patients with ear infections from low-risk groups, and the Philadelphia protocol only considers low-risk those cases with an "unremarkable exam" [8]. On the other hand, one study found that none of the 13 infants excluded from the low-risk group for only otitis media had systemic infections [12], and in a second report no infant excluded from the low-risk group because of otitis media had a systemic infection [11]. (See "Strategies for the evaluation of fever in neonates and infants (less than three months of age)".)Similarly, a report of 130 patients 60 days and younger with AOM confirmed by tympanocentesis found that the presence of AOM did not predict a higher risk for SBI in either febrile or afebrile patients [54]. None of the afebrile infants with AOM or the febrile infants who were otherwise determined to be at low risk developed an SBI. On the other hand, 14 percent of high-risk infants with AOM also had a serious bacterial illness.Finally, in a study of 40 infants zero to eight weeks of age with isolated otitis media who underwent a full sepsis evaluation and tympanocentesis, all afebrile infants had negative cultures of blood, urine, and CSF [55]. Two febrile infants had an SBI.These findings suggest that febrile infants with AOM should be evaluated and managed similarly to febrile infants without AOM. The decision to forego a full sepsis evaluation in afebrile infants with AOM should be made with caution. The practitioner must consider the possibility of masking an SBI and the difficult situation that will arise if the infant becomes febrile and ill-RMATION FOR PATIENTS?—?UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5th?to 6th?grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th?to 12th?grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.) Basics topics (see "Patient information: Fever in children (The Basics)") Beyond the Basics topics (see "Patient information: Fever in children")SUMMARY AND RECOMMENDATIONS?—?Given the risk and potentially adverse consequences of unrecognized and/or untreated serious bacterial infection (SBI), a cautious approach to neonates (0 to 28 days) and young infants (29 to 90 days) with fever (T ≥ 38?C or 100.4?F) is prudent. (See "Definition and etiology of fever in neonates and infants (less than three months of age)".)Definitive data to guide patient evaluation are lacking, and some categories that define high-risk groups such as age and white blood cell (WBC) count are arbitrary. (See "Strategies for the evaluation of fever in neonates and infants (less than three months of age)".)Consequently, each patient and each clinical situation must be evaluated individually. Bearing in mind that the predictors of SBI used to classify febrile infants into risk subsets aid in the assessment of risk, but do not eliminate risk, we offer the following recommendations:Neonates (0 to 28 days)We recommend that all neonates with a rectal temperature ≥38?C have blood, urine, and CSF cultures performed regardless of clinical appearance. We recommend a chest radiograph be obtained in those with any sign or symptom of pulmonary disease. We recommend that these neonates be admitted to the hospital (Grade 1B). Because of the high rates of serious bacterial infection and high risk of mortality if untreated, we recommend empiric treatment with antibiotics (Grade 1B)?(table 2). (See 'Neonates (0 to 28 days)'?above.) Ampicillin?and gentamicin?or ampicillin and cefotaxime?provide adequate empiric therapy for the pathogens that are common in this age group. (See 'Neonates (0 to 28 days)'?above.) Infants ≤28 days who are ill-appearing and lethargic, demonstrate mucocutaneous vesicles, have had seizures, display a CSF pleocytosis, or exhibit elevated liver transaminases may have a CNS or disseminated herpes simplex virus (HSV) infection. In this select population of infants, we suggest initiating treatment with acyclovir?(60 mg/kg per day divided three times daily) (Grade 2B). For patients who are not initially treated with acyclovir, we suggest adding it if the bacterial cultures remain negative at 48 to 72 hours, and the patient has not improved clinically (Grade 2C). Routine use of acyclovir is not indicated in the management of febrile neonates. Laboratory studies to confirm the diagnosis of HSV should be sent prior to the initiation of acyclovir. (See 'Neonates (0 to 28 days)'?above.)Ill-appearing infants (29 to 90 days)We recommend that infants who are ill-appearing have a full laboratory evaluation including blood, urine, and CSF cultures and receive parenteral antibiotics. Those who have signs of pulmonary disease should also receive a chest radiograph. We recommend that these patients receive empiric antibiotic therapy with cefotaxime?or ceftriaxone?and be admitted to the hospital for ongoing parenteral antibiotic therapy (Grade 1B). (See 'Ill-appearing infants (29 to 90 days)'?above.) Empiric antibiotic therapy should also be adjusted based on specific clinical findings as follows (see 'Ill-appearing infants (29 to 90 days)'?above):Vancomycin?should be given to those infants with evidence of soft tissue infection. (See "Evaluation and management of suspected methicillin-resistant Staphylococcus aureus skin and soft tissue infections in children", section on 'Severe SSTI'.) Vancomycin?should be given to those infants with CSF pleocytosis to treat meningitis caused by S. pneumoniae that is not susceptible to cefotaxime?or ceftriaxone?and, in infants 29 to 60 days of age, ampicillin?should also be given to cover Listeria monocytogenes (table 2). (See "Treatment, prognosis, and prevention of Listeria monocytogenes infection".)Well appearingInfants 29 to 60 days of ageWe suggest that well-appearing infants 29 to 60 days of age with a temperature ≥38.0?C undergo a complete history and physical examination with appropriate laboratory evaluation including CBC, blood culture, urinalysis and culture, and CSF for cell count and culture. Although lumbar puncture may not be necessary in some well-appearing infants, including those with bronchiolitis or a positive rapid test for influenza, we suggest that lumbar puncture be performed if empiric antibiotics are prescribed, including in infants who have an abnormal urinalysis or otitis media. A stool culture is suggested if diarrhea is present. (See '29 to 60 days'?above.) We suggest that a chest radiograph be obtained only in infants with at least one clinical sign of pulmonary disease (respiratory rate >50 breaths/minute, rales, rhonchi, retractions, wheezing, coryza, grunting, stridor, nasal flaring, or cough). (See '29 to 60 days'?above.) Infants who have an abnormal urinalysis, CSF pleocytosis, or an abnormal chest radiograph require presumptive antibiotic therapy (table 2). Infants with pneumonia or meningitis should be admitted to the hospital. We suggest that infants with an abnormal urinalysis also be admitted (Grade 2C). (See '29 to 60 days'?above.) Infants 29 to 60 days of age who are well-appearing and have a normal laboratory evaluation and chest radiograph, when one is performed, can be sent home as long as reliable follow-up within 24 hours can be arranged (either by phone or by return visit to the clinician). We suggest treatment with parenteral antibiotics (Grade 2C). Ceftriaxone?(50 mg/kg in a single dose) is preferred because of its antimicrobial spectrum and long duration of action. This recommendation emphasizes the small but potentially severe risk of not treating an SBI as opposed to the more common but typically less severe risks associated with parenteral antibiotic administration. We suggest that CSF be obtained if antibiotics are given empirically. (See '29 to 60 days'?above.)Infants 61 to 90 days of ageWe suggest that a CBC, urinalysis, and cultures of blood and urine be obtained in well-appearing infants. Those who have signs of pulmonary disease should receive a chest radiograph as well. In addition, WBC outside of the normal range of 5000 to 15,000/microL suggests the need for lumbar puncture followed by treatment with parenteral antibiotics until all cultures are final (table 2). we suggest that CSF be obtained when empiric antibiotics are prescribed. (See 'Lumbar puncture'?above and '61 to 90 days'?above.) Infants with an abnormal urinalysis should be treated for urinary tract infection. (See '61 to 90 days'?above and "Acute management, imaging, and prognosis of urinary tract infections in children".)Use of UpToDate is subject to the Subscription and License Agreement. REFERENCESBaker MD, Avner JR, Bell LM. Failure of infant observation scales in detecting serious illness in febrile, 4- to 8-week-old infants. Pediatrics 1990; 85:1040. DeAngelis C, Joffe A, Wilson M, Willis E. Iatrogenic risks and financial costs of hospitalizing febrile infants. Am J Dis Child 1983; 137:1146. Baraff LJ. Management of fever without source in infants and children. Ann Emerg Med 2000; 36:602. Mower WR, Sachs C, Nicklin EL, Baraff LJ. Pulse oximetry as a fifth pediatric vital sign. Pediatrics 1997; 99:681. Walsh-Kelly C, Nelson DB, Smith DS, et al. Clinical predictors of bacterial versus aseptic meningitis in childhood. Ann Emerg Med 1992; 21:910. Dagan R, Sofer S, Phillip M, Shachak E. Ambulatory care of febrile infants younger than 2 months of age classified as being at low risk for having serious bacterial infections. J Pediatr 1988; 112:355. Anbar RD, Richardson-de Corral V, O'Malley PJ. Difficulties in universal application of criteria identifying infants at low risk for serious bacterial infection. J Pediatr 1986; 109:483. Baker MD, Bell LM, Avner JR. Outpatient management without antibiotics of fever in selected infants. N Engl J Med 1993; 329:1437. Baskin MN, O'Rourke EJ, Fleisher GR. Outpatient treatment of febrile infants 28 to 89 days of age with intramuscular administration of ceftriaxone. J Pediatr 1992; 120:22. Baker MD, Bell LM, Avner JR. The efficacy of routine outpatient management without antibiotics of fever in selected infants. Pediatrics 1999; 103:627. Jaskiewicz JA, McCarthy CA, Richardson AC, et al. Febrile infants at low risk for serious bacterial infection--an appraisal of the Rochester criteria and implications for management. Febrile Infant Collaborative Study Group. Pediatrics 1994; 94:390. Dagan R, Powell KR, Hall CB, Menegus MA. Identification of infants unlikely to have serious bacterial infection although hospitalized for suspected sepsis. J Pediatr 1985; 107:855. Broner CW, Polk SA, Sherman JM. Febrile infants less than eight weeks old. Predictors of infection. Clin Pediatr (Phila) 1990; 29:438. Chiu CH, Lin TY, Bullard MJ. Identification of febrile neonates unlikely to have bacterial infections. Pediatr Infect Dis J 1997; 16:59. Crain EF, Gershel JC. Which febrile infants younger than two weeks of age are likely to have sepsis? A pilot study. Pediatr Infect Dis J 1988; 7:561. Bonsu BK, Chb M, Harper MB. Identifying febrile young infants with bacteremia: is the peripheral white blood cell count an accurate screen? Ann Emerg Med 2003; 42:216. Bonsu BK, Harper MB. Utility of the peripheral blood white blood cell count for identifying sick young infants who need lumbar puncture. Ann Emerg Med 2003; 41:206. Maniaci V, Dauber A, Weiss S, et al. Procalcitonin in young febrile infants for the detection of serious bacterial infections. Pediatrics 2008; 122:701. Dauber A, Weiss S, Maniaci V, et al. Procalcitonin levels in febrile infants after recent immunization. Pediatrics 2008; 122:e1119. Tan TQ. Procalcitonin in young febrile infants for the detection of serious bacterial infections: is this the "holy grail"? Pediatrics 2008; 122:1117. Pantell RH, Newman TB, Bernzweig J, et al. Management and outcomes of care of fever in early infancy. JAMA 2004; 291:1203. Zorc JJ, Levine DA, Platt SL, et al. Clinical and demographic factors associated with urinary tract infection in young febrile infants. Pediatrics 2005; 116:644. Hoberman A, Wald ER, Reynolds EA, et al. Is urine culture necessary to rule out urinary tract infection in young febrile children? Pediatr Infect Dis J 1996; 15:304. American College of Emergency Physicians Clinical Policies Committee, American College of Emergency Physicians Clinical Policies Subcommittee on Pediatric Fever. Clinical policy for children younger than three years presenting to the emergency department with fever. Ann Emerg Med 2003; 42:530. Bramson RT, Meyer TL, Silbiger ML, et al. The futility of the chest radiograph in the febrile infant without respiratory symptoms. Pediatrics 1993; 92:524. Correa AG. Diagnostic approach to pneumonia in children. Semin Respir Infect 1996; 11:131. Kadish HA, Loveridge B, Tobey J, et al. Applying outpatient protocols in febrile infants 1-28 days of age: can the threshold be lowered? Clin Pediatr (Phila) 2000; 39:81. Ferrera PC, Bartfield JM, Snyder HS. Neonatal fever: utility of the Rochester criteria in determining low risk for serious bacterial infections. Am J Emerg Med 1997; 15:299. Ishimine P. Fever without source in children 0 to 36 months of age. Pediatr Clin North Am 2006; 53:167. Larsen JW, Sever JL. Group B Streptococcus and pregnancy: a review. Am J Obstet Gynecol 2008; 198:440. Byington CL, Rittichier KK, Bassett KE, et al. Serious bacterial infections in febrile infants younger than 90 days of age: the importance of ampicillin-resistant pathogens. Pediatrics 2003; 111:964. Sadow KB, Derr R, Teach SJ. Bacterial infections in infants 60 days and younger: epidemiology, resistance, and implications for treatment. Arch Pediatr Adolesc Med 1999; 153:611. Bonadio WA, Hennes H, Smith D, et al. Reliability of observation variables in distinguishing infectious outcome of febrile young infants. Pediatr Infect Dis J 1993; 12:111. Bachur RG, Harper MB. Predictive model for serious bacterial infections among infants younger than 3 months of age. Pediatrics 2001; 108:311. Crain EF, Bulas D, Bijur PE, Goldman HS. Is a chest radiograph necessary in the evaluation of every febrile infant less than 8 weeks of age? Pediatrics 1991; 88:821. Hellerstein S. Antibiotic treatment for urinary tract infections in pediatric patients. Minerva Pediatr 2003; 55:395. Dayan PS, Hanson E, Bennett JE, et al. Clinical course of urinary tract infections in infants younger than 60 days of age. Pediatr Emerg Care 2004; 20:85. Hsiao AL, Chen L, Baker MD. Incidence and predictors of serious bacterial infections among 57- to 180-day-old infants. Pediatrics 2006; 117:1695. McGowan KL, Foster JA, Coffin SE. Outpatient pediatric blood cultures: time to positivity. Pediatrics 2000; 106:251. Garcia-Prats JA, Cooper TR, Schneider VF, et al. Rapid detection of microorganisms in blood cultures of newborn infants utilizing an automated blood culture system. Pediatrics 2000; 105:523. Levine DA, Platt SL, Dayan PS, et al. Risk of serious bacterial infection in young febrile infants with respiratory syncytial virus infections. Pediatrics 2004; 113:1728. Greenes DS, Harper MB. Low risk of bacteremia in febrile children with recognizable viral syndromes. Pediatr Infect Dis J 1999; 18:258. Krief WI, Levine DA, Platt SL, et al. Influenza virus infection and the risk of serious bacterial infections in young febrile infants. Pediatrics 2009; 124:30. Byington CL, Enriquez FR, Hoff C, et al. Serious bacterial infections in febrile infants 1 to 90 days old with and without viral infections. Pediatrics 2004; 113:1662. Melendez E, Harper MB. Utility of sepsis evaluation in infants 90 days of age or younger with fever and clinical bronchiolitis. Pediatr Infect Dis J 2003; 22:1053. Antonow JA, Hansen K, McKinstry CA, Byington CL. Sepsis evaluations in hospitalized infants with bronchiolitis. Pediatr Infect Dis J 1998; 17:231. Bilavsky E, Shouval DS, Yarden-Bilavsky H, et al. A prospective study of the risk for serious bacterial infections in hospitalized febrile infants with or without bronchiolitis. Pediatr Infect Dis J 2008; 27:269. Titus MO, Wright SW. Prevalence of serious bacterial infections in febrile infants with respiratory syncytial virus infection. Pediatrics 2003; 112:282. Purcell K, Fergie J. Concurrent serious bacterial infections in 2396 infants and children hospitalized with respiratory syncytial virus lower respiratory tract infections. Arch Pediatr Adolesc Med 2002; 156:322. Kuppermann N, Bank DE, Walton EA, et al. Risks for bacteremia and urinary tract infections in young febrile children with bronchiolitis. Arch Pediatr Adolesc Med 1997; 151:1207. Purcell K, Fergie J. Concurrent serious bacterial infections in 912 infants and children hospitalized for treatment of respiratory syncytial virus lower respiratory tract infection. Pediatr Infect Dis J 2004; 23:267. Hall CB, Powell KR, Schnabel KC, et al. Risk of secondary bacterial infection in infants hospitalized with respiratory syncytial viral infection. J Pediatr 1988; 113:266. Oray-Schrom P, Phoenix C, St Martin D, Amoateng-Adjepong Y. Sepsis workup in febrile infants 0-90 days of age with respiratory syncytial virus infection. Pediatr Emerg Care 2003; 19:314. Turner D, Leibovitz E, Aran A, et al. Acute otitis media in infants younger than two months of age: microbiology, clinical presentation and therapeutic approach. Pediatr Infect Dis J 2002; 21:669. Nozicka CA, Hanly JG, Beste DJ, et al. Otitis media in infants aged 0-8 weeks: frequency of associated serious bacterial disease. Pediatr Emerg Care 1999; 15:252.GRAPHICSCerebrospinal fluid (CSF) patterns and diagnosis of viral meningitisPathogen WBC (cells/mm3) RBC Glucose (mg/dL) Protein (mg/dL) Viral diagnosis Enterovirus100-1000NoneNL/SL↓<160Cell culture: NP, rectal, CSF; PCR: CSFHerpes simplex virus~100None or ↑~~100 or higherCell culture: skin or mucosal lesion; PCR: CSF; Brain biopsyEpstein Barr virus↑NoneNL↑Cell culture and PCR: CSF (research laboratories)Cytomegalovirus↑None↓↑Cell culture as CSFPCRLymphocytic choriomeningitis virus↑NoneNL/SL↓NL/SL ↑Serology, cell culture and PCRInfluenzaNL/SL↑NoneNLNL/SL↑Cell culture: NP and CSFArboviruses <200 None NL ↑Serum serology testingCell culture: research laboratoriesWEE virus: PCR: CSFEastern equine encephalitis 400-4000 ? Western equine encephalitis (WEE) ≤2000 ? West Nile virus <200 Up to 900 St. Louis encephalitis virus <200 ~200 NL: normal; SL: slightly; NP: nasopharyngeal aspirate; PCR: polymerase chain reaction; ↓: decrease; ↑: increase. Data from: Feigin RD, Shackelford PG. Value of repeat lumbar puncture in the differential diagnosis of meningitis. N Engl J Med 1973;289: 571 and Negrini B, Kelleher KJ, Wald ER. Cerebrospinal fluid findings in aseptic versus bacterial meningitis. Pediatrics 2000; 105:316 and Rotbart HA. Viral meningitis. Semin Neurol 2000; 20:277 and Sawyer MH. Enterovirus infections: diagnosis and treatment. Pediatr Infect Dis J 1999; 18:1033 and Simko JP, Caliendo AM, Hogle K, Versalovic J. Differences in laboratory findings for cerebrospinal fluid specimens obtained from patients with meningitis or encephalitis due to herpes simplex virus (HSV) documented by detection of HSV DNA. Clin Infect Dis 2002; 35:414. Empirical treatment of suspected SBI in febrile infants less than 90 days of age*Age Most likely organism Empiric treatment Neonate - (≤28 days)Common: Group B Streptococcus, E. coliLess common: Listeria monocytogenes, Enterococcus, S. aureus, other Gram negative organisms, Herpes simplex virusAmpicillin & cefotaxime OR ampicillin & aminoglycoside? & acyclovir,Δ as indicated (see footnotes)Infant - (29 to 90 days)Common: S. pneumoniae, H. influenzae, N. meningiditisLess common: Group B Streptococcus, E. coli, S. aureus, Enterococcus, Listeria monocytogenes, Pseudomonas sp., other Gram negative organismsWell-appearing, no CSF pleocytosis:Ceftriaxone OR cefotaximeCSF pleocytosis or ill-appearing:Vancomycin & ampicillin & ceftriaxone OR cefotaxime?* Broad spectrum coverage is prudent until an organism is identified.? The choice of regimen should be based on local susceptibility patterns of E. coli and likelihood of L. monocytogenes infection.Δ Acyclovir is indicated in infants ≤28 days with ill-appearance, mucocutaneous vesicles, seizures, or CSF pleocytosis.? This regimen does not include an aminoglycoside and may not optimally cover infection with L. monocytogenes or resistant Gram negative organisms, especially when meningitis is present. Antibiotic therapy should be adjusted accordingly if infection with these pathogens is identified. ................
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