Neonatal Fever v6.0: ED Phase (0-28 days old) Approval & Citation Summary of Version Changes Explanation of Evidence Ratings PHASE I (E.D.) Inclusion Criteria · Fever ≥38 C (or a reliable Urgent Care Transfer history of fever) or hypothermia Guidelines (for 0-28 days) <36 C in children <28 days of age Well appearing neonates with fever transfer via POV to an ED Exclusion Criteria · Patients currently admitted to Ill appearing neonates with fever: ICU or admitted >3 days · Initiate transport immediately · Known immunodeficiency or · Attempt to obtain labs cancer · Give antibiotics (IV or IM) · Patients with central venous catheters or VP shunts ! Other differential Begin clinical assessment diagnosis for severely ill neonates Focal Infection Off Yes (e.g., omphalitis, pneumonia) Pathway CSF Normative values No 0-1 month: CSF WBC <20/mm3 HSV work up indications >I month: CSF WBC Perform c o m p l e t e w o r k u p and begin <10/mm3 acyclovir for any of the following: · UA, urine culture Historical and clinical features · CBC with diff, Blood culture · severe illness · CSF studies · hypothermia · lethargy ! · HSV work up if indicated (see box) · CXR and respiratory viral panel (if · seizures respiratory symptoms) · hepatosplenomegaly If CSF · postnatal HSV contact pleocytosis · Stool PCR (if diarrhea) · vesicular rash consider · conjunctivitis CSF Rapid Viral Qual. · interstitial pneumonitis PCR Laboratory features · thrombocytopenia · CSF pleocytosis >20 WBC/mm3 Inability to obtain Begin empiric treatment without clear bacterial infection CSF in ED · Ampicillin and cefotaxime (or ceftazidime if (e.g., + Gram stain) CCoonnssiiddeerrationss ffoorr cefotaxime unavailable) PPrrettreated CCSSFF · Acyclovir if HSV work up performed · Admit all patients · Administer antibiotics (GOAL: within 60 minutes) ! · Refer to IR for lumbar Go to In well- puncture as inpatient appearing · Rapid CSF Bacterial PCR Inpatient infants with can be sent on pre-treated Phase multiple maternal CSF that demonstrates (0-28d) HSV risk factors, pleocytosis consider HSV work up For questions concerning this pathway, Last Updated: August 2019 contact: [email protected] Next Expected Revision: January 2024 © 2019 Seattle Children’s Hospital, all rights reserved, Medical Disclaimer Neonatal Fever v6.0: ED Phase (29-56 days old) Approval & Citation Summary of Version Changes Explanation of Evidence Ratings PHASE I (E.D.) Urgent Care Transfer Inclusion Criteria Guidelines (for 29-56 days) · Fever ≥38 C (or a reliable history of fever) or hypothermia Ill appearing neonates with <36 C in children 29-56 days of fever: age · Initiate transport immediately Exclusion Criteria · Attempt to obtain labs · Patients currently admitted to · Give antibiotics (IV or IM) ICU or admitted >3 days · Known immunodeficiency or Does not meet low risk criteria: cancer · Transfer to ED for additional · Patients with central venous work up and antibiotics ! catheters or VP shunts If CSF pleocytosis consider Focal Infection Off Yes CSF Rapid Viral Qual. (e.g., omphalitis, pneumonia) Pathway PCR No Bronchiolitis? CONSIDER (increased work of breathing, cough, Yes NEONATAL FEVER 29- tachypnea, wheezing) 56 days W/BRONCH ED PHASE No Low Risk Criteria Inability to obtain · Well-appearing CSF in ED · Previously healthy Considerations for · CBC with diff Considerations for · Full term (≥37 weeks) PPrertertereaatetedd C CSSFF · No focal bacterial infection · Blood culture · Negative urinalysis · UA, urine culture · Administer antibiotics · WBC >5,000 and <15,000 mm3 · CXR and respiratory viral panel 3 (GOAL: within 60 minutes) · Absolute bands <1,500 mm (if respiratory symptoms) · Refer to IR for lumbar · No discrete infiltrates on CXR if · Stool PCR (if diarrhea) puncture as inpatient done · Rapid CSF Bacterial PCR can be sent on pre-treated CSF that demonstrates pleocytosis ! Meets all low risk criteria? Ceftriaxone contraindicated with hyperbilirubinemia · Obtain CSF studies · Begin ceftriaxone Yes No · Considerations for severely ill patients and other clinical scenarios · Admit Discharge Criteria (meets all) · Eating well and well appearing · No social/family concerns Go to · Reliable follow-up in 12- No Inpatient 24 hours Admit for observation Phase · Outpatient plan accepted CSF studies and antibiotics if worsens by PMD and family (29-56d) For questions concerning this pathway, contact: [email protected] Last Updated: August 2019 © 2019 Seattle Children’s Hospital, all rights reserved, Medical Disclaimer Next Expected Revision: January 2024 Neonatal Fever v6.0: Inpatient Phase (0-28 days old) Approval & Citation Summary of Version Changes Explanation of Evidence Ratings PHASE II (INPATIENT) Inclusion Criteria · Fever ≥38 C (or a reliable history of fever) or hypothermia <36 C in children <28 days of ! age Exclusion Criteria If CSF · Patients currently admitted to pleocytosis ICU or admitted >3 days consider Known immunodeficiency or CSF Rapid Viral Qual. · PCR cancer · Patients with central venous catheters or VP shunts Yes CSF Pleocytosis No Review Urinalysis >20WBC/mm3? results Positive Negative Cefotaxime Ampicillin + Ampicillin + Monotherapy Cefotaxime gentamicin (or Ceftazidime if (or Ceftazidime if Cefotaxime unavailable) When to Cefotaxime unavailable) discontinue acyclovir Inability to obtain · Treat specific condition CSF in ED · Narrow antibiotic agent CCoonnssiiddeerrationss ffoorr Daily re-evaluation Pos. cultures if possible PPrrettreated CCSSFF · If HSV+, transfer to ID service · ED administers antibiotics · Refer to IR for lumbar Neg. cultures puncture as inpatient · Rapid CSF Bacterial PCR Improving and meets No Further evaluation can be sent on pre-treated discharge criteria? per primary team CSF that demonstrates pleocytosis Yes Discharge Criteria (Meets all) · Tolerating PO · Well-appearing Discharge · At 36 hours if cultures ! Instructions negative Consider · PMD f/u within · HSV discharge criteria discharge at 48-72 hours · Adequate follow-up 24 hours if non-HSV · PMD and family agree viral studies positive with plan & patient well-appearing For questions concerning this pathway, Last Updated: August 2019 contact: [email protected] Next Expected Revision: January 2024 © 2019 Seattle Children’s Hospital, all rights reserved, Medical Disclaimer Neonatal Fever v6.0: ED Phase (29-56 days old) with Bronchiolitis Approval & Citation Summary of Version Changes Explanation of Evidence Ratings PHASE I (E.D.) Inclusion Criteria · Fever ≥38 C (or a reliable history of fever) or hypothermia <36 C in children 29-56 days of age with signs of bronchiolitis Exclusion Criteria · Patients currently admitted to ICU or admitted >3 days · Known immunodeficiency or ! cancer · Patients with central venous Onset of NEW fever catheters or VP shunts during hospitalization in In patients PRESENTING with patients with bronchiolitis can fever and bronchiolitis, the risk of be indicative of a serious bbaacctteerreemmiiaa aanndd mmeenniinnggiittiiss iiss llooww.. bacterial infection. UTI should be considered in Symptoms of Bronchiolitis: patients who are persistently (increased work of breathing, cough, symptomatic with fever or tachypnea, wheezing) vomiting. Signs of poor perfusion or mental status Continue workup per Neonatal YES changes or sepsis score > 3 Fever (29-56d) pathway NO Consider UA/Culture in patients who are persistently febrile or vomiting UA – OR UA + UA NOT INDICATED Blood CX Off CONSIDER BRONCHIOLITIS Pathway PATHWAY Ceftriaxone Admit to iinpattiientt on UTII and Brronchiiolliittiis pathway For questions concerning this pathway, Last Updated: August 2019 contact: [email protected] Next Expected Revision: January 2024 © 2019 Seattle Children’s Hospital, all rights reserved, Medical Disclaimer Neonatal Fever v6.0: Inpatient Phase (29-56 days old) Approval & Citation Summary of Version Changes Explanation of Evidence Ratings PHASE II (INPATIENT) Inclusion Criteria · Fever ≥38 C (or a reliable history of fever) or hypothermia <36 C in children 29-56 days of ! age Exclusion Criteria If CSF · Patients currently admitted to pleocytosis ICU or admitted >3 days consider Known immunodeficiency or CSF Rapid Viral Qual. · PCR cancer · Patients with central venous catheters or VP shunts · Treat specific condition · Consider LP in patients with ! bacteremia if not done prior Daily re-evaluation Positive cultures · Begin antibiotics if not begun Ceftriaxone prior; narrow antibiotic agent if contraindicated with possible Calcium containing fluids or hyperbili Considerations for Pretreated CSF Negative cultures · Rapid CSF Bacterial PCR can be sent on pre-treated CSF that demonstrates pleocytosis Improving and meets ! discharge criteria? Consider discharge at 24 hours if non-HSV viral studies positive No & patient well-appearing Yes Further evaluation per Discharge Criteria primary team (Meets all) · Tolerating PO · Well-appearing · At 36 hours if cultures negative Discharge and antibiotics begun Instructions · At 24 hours if cultures negative · PMD f/u within and no antibiotics begun 48-72 hours · Adequate follow-up · PMD and family agree with plan For questions concerning this pathway, Last Updated: August 2019 contact: [email protected] Next Expected Revision: January 2024 © 2019 Seattle Children’s Hospital, all rights reserved, Medical Disclaimer Background Fever is a common presenting symptom in neonates and young infants: • 12-28% will have a serious bacterial infection (which include bacteremia/sepsis,