Diagnosis
H&P
Categorize into <28 days (or <30 days) old, 1 to 3 months of age, >3 months of age.
Decision-making tools like the Step-by-Step approach or Rochester Criteria.
Common presentation:
Neonates (<28 days) get a complete sepsis workup. Routine LP and CXR no longer recommended for older babies.
Diagnostic studies:
-Complete sepsis workup: Blood Cx, CBC + Manual diff; UA, Urine Cx; CXR; LP; Stool Cx and Fecal WBCs if diarrhea is present.
-CRP, Procalcitonin (for Step-by-Step).
Consider, CMP, RSV antigen, Flu A viral RNA, Flu B viral RNA.
Diagnostic algorithm (AFP 2013).
DDx and causes:
Treatment
Neonates (<28 days) get a complete sepsis workup PLUS start IV antibiotics.
-Ampicillin and Cefotaxime or preferably, Ampicillin & Gentamycin.
-[PLUS Acyclovir until the viral culture of LP comes back negative before you discharge the patient if LP was done]
-Tylenol for fever prn.
-Repeat CBC in the am.
-Children 29–90 days old who appear to be nontoxic and have normal labs (CBC and UA), can be sent home with precautions and with follow-up in 24 hours.
–Children 3–36 months of age who appear nontoxic and have a fever of temperature <39.0°C (102.2°F), Observation only, with close follow-up, is recommended without labs.
-Consider testing for neonatal HSV infection in patients with risk factors – maternal infection at the time of delivery, use of fetal scalp electrodes, vaginal delivery, CSF pleocytosis, or herpetic lesions. Also, consider testing for HSV when a child doesn’t respond to antibiotics.
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LP = Lumbar puncture; Cx= Culture; CXR = Chest Radiograph.
“Any infant younger than 29 days and any child (regardless of age) who appears toxic should get a complete sepsis workup and be admitted for observation until blood cultures are back or the cause of the fever is discovered and treated. However, nontoxic-appearing children one to 36 months of age, who have a fever with no apparent source and who have received the appropriate vaccinations, could undergo screening laboratory analysis and be sent home with close follow-up” (AFP 2007 Jun 15;75(12):1805-1811).
For infants older than 2 months, vancomycin and cefotaxime are the empiric antibiotic choices for sepsis.
Important links for Fever in a neonate.
Further Reading
Am Fam Physician. 2013 Feb 15;87(4):254-260. Evaluation of Fever in Infants and Young Children. https://www.aafp.org/afp/2013/0215/p254.html
Am Fam Physician. 2007 Jun 15;75(12):1805-1811.