Definition of Fever Without a Source: Temperature >=38.0 C/100.4 F in an infant from one of the age groups below.
Age-appropriate culture evaluation per local algorithm should be completed before antibiotic administration.
Modification of therapy is indicated if a focal source is identified or suspected:
- Refer to Severe Sepsis section for infants who meet criteria for severe sepsis.
- Refer to Meningitis section if meningitis is suspected based on specific clinical signs (e.g. seizure, neurologic changes) or symptoms or CSF pleocytosis.
- Refer to Herpes Simplex Virus section if neonatal HSV is suspected.
- Consult ID for suspected bone or joint infection.
- Conventional antibiotics used for fever without a source do not provide sufficient activity for common skin flora - additional gram-positive coverage is needed if signs of skin/soft tissue infection are present.
| Condition | Major Pathogens | First Choice Therapy | Alternative Therapy | Comments |
|---|---|---|---|---|
|
Fever without a source 0-28 days, community-onset, previously healthy (admitted from home), without symptoms or signs indicating high suspicion for meningitis (applies to most infants undergoing evaluation) |
Enteric gram- negative bacteria Group B streptococcus
|
Ampicillin * AND Gentamicin* Acyclovir should not be routinely added based on fever alone - refer to Herpes Simplex Virus section for indications |
Eligible per local evaluation algorithm (BCH OAK refer to REVISE algorithm - link requires password log in to Box) or other clinical pathway: For patients age 22-28 days treated via defined evaluation pathway enabling discharge without hospitalization per AAP guidelines, may follow pathway-recommended first choice therapy. |
Refer to Neonatal Dosing Guideline for antibiotic doses and intervals Therapy should not be broadened based on ongoing fever alone. Many infections in this age group are viral. Consider evaluation and testing for viral infection based on clinical presentation. |
|
Fever without a source 29-60 days old, community-onset, previously healthy (presenting from home), without symptoms or signs indicating high suspicion for meningitis (applies to most infants undergoing evaluation) |
Streptococcus pneumoniae Enteric gram-negative bacteria Group B streptococcus
|
Eligible for observation without antibiotics per local evaluation algorithm (BCH OAK refer to REVISE algorithm - link requires password log in to Box): Antibiotic treatment is not indicated ------------------------ Empiric antibiotic recommended per local evaluation algorithm: Ceftriaxone 50 mg/kg/dose IV q24h Acyclovir should not be routinely added based on fever alone - refer to Herpes Simplex Virus section for indications |
Therapy should not be broadened based on ongoing fever alone. Many infections in this age group are viral. Consider evaluation and testing for viral infection based on clinical presentation Refer to Urinary Tract Infection section if initial evaluation indicates UTI is likely (pyuria on urinalysis). Initial oral therapy may be appropriate based on evaluating provider discretion |
References:
Greenhow TG, Cantey JB. The disputed champion: ampicillin and gentamicin for febrile young infants. Hosp Pediatr 2017;7:499-501.
Bruno E, et al. During the emergency department evaluation of a well-appearing neonate with fever, should empiric acyclovir be initiated? Clinical Practice Guideline, American Academy of Emergency Medicine, 2017.
Leazer R, et al. A meta-analysis of the rates of Listeria monocytogenes and Enterococcus in febrile infants. Hosp Pediatr 2016;6:187-195.
American Academy of Pediatrics. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. 32nd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2021.
Pediatric Empiric Antimicrobial Therapy Guidelines
This is a subsection of the UCSF Benioff Children’s Hospitals Empiric Antimicrobial Therapy Guidelines, developed by the Pediatric Antimicrobial Stewardship Programs at each campus to inform initial selection of empiric antimicrobial therapy for children at the UCSF Benioff Children’s Hospitals and affiliated outpatient sites.
These are guidelines only and not intended to replace clinical judgment. Modification of therapy may be indicated based on patient comorbidities, previous antibiotic therapy or infection history. Doses provided are usual doses but may require modification based on patient age or comorbid conditions. Refer to Pediatric Antimicrobial Dosing Guideline for further guidance on dosing in children, and Neonatal Dosing Guideline for infants < 1 month of age. Consult a pediatric pharmacist for individualized renal or hepatic dose adjustment. Durations provided are usual recommendations for patients who are responding appropriately to therapy. For additional guidance, please contact Pediatric Infectious Diseases (ID) or the Pediatric Antimicrobial Stewardship Program (ASP) at the campus where your patient is receiving care.
For questions or feedback about these guidelines, please email primary content owners, Rachel Wattier, Pediatric ASP Medical Director at BCH SF and Prachi Singh, Pediatric ASP Medical Director at BCH OAK.
The content of these guidelines was updated in July 2021. See Summary and Rationale for Changes (password login to Box needed) for detailed explanations of the content changes.