This guideline is intended for physicians working in emergency departments.
Inclusion Criteria
This guideline applies to previously healthy term infants and children, appropriately immunized for age, with ages as described in each critical question.
Exclusion Criteria
This guideline excludes neonates, prematurely born infants, and pediatric patients considered to be at high risk such as those with significant congenital abnormalities, with serious illnesses preceding the onset of fever, and in an immunocompromised state.
Critical Questions:
- For well-appearing immunocompetent infants and children aged 2 months to 2 years presenting with fever (≥38.0°C [100.4°F]), are there clinical predictors that identify patients at risk for urinary tract infection?
Level C Recommendation:
Infants and children at increased risk for urinary tract infection include females younger than 12 months, uncircumcised males, nonblack race, fever duration greater than 24 hours, higher fever (≥39°C), negative test result for respiratory pathogens, and no obvious source of infection. Although the presence of a viral infection decreases the risk, no clinical feature has been shown to effectively exclude urinary tract infection. Physicians should consider urinalysis and urine culture testing to identify urinary tract infection in well-appearing infants and children aged 2 months to 2 years with a fever ≥38°C (100.4°F), especially among those at higher risk for urinary tract infection. - For well-appearing febrile infants and children aged 2 months to 2 years undergoing urine testing, which laboratory testing method(s) should be used to diagnose a urinary tract infection?
Level B Recommendation:
Physicians can use a positive test result for any one of the following to make a preliminary diagnosis of urinary tract infection in febrile patients aged 2 months to 2 years: urine leukocyte esterase, nitrites, leukocyte count, or Gram's stain.
Level C Recommendations:
(1) Physicians should obtain a urine culture when starting antibiotics for the preliminary diagnosis of urinary tract infection in febrile patients aged 2 months to 2 years.
(2) In febrile infants and children aged 2 months to 2 years with a negative dipstick urinalysis result in whom urinary tract infection is still suspected, obtain a urine culture. - For well-appearing immunocompetent infants and children aged 2 months to 2 years presenting with fever (≥38.0°C [100.4°F]), are there clinical predictors that identify patients at risk for pneumonia for whom a chest radiograph should be obtained?
Level B Recommendation:
In well-appearing immunocompetent infants and children aged 2 months to 2 years presenting with fever (≥38°C [100.4°F]) and no obvious source of infection, physicians should consider obtaining a chest radiograph for those with cough, hypoxia, rales, high fever (≥39°C), fever duration greater than 48 hours, or tachycardia and tachypnea out of proportion to fever.
Level C Recommendation:
In well-appearing immunocompetent infants and children aged 2 months to 2 years presenting with fever (≥38°C [100.4°F]) and wheezing or a high likelihood of bronchiolitis, physicians should not order a chest radiograph. - For well-appearing immunocompetent full-term infants aged 1 month to 3 months (29 days to 90 days) presenting with fever (≥38.0ºC [100.4°F]), are there predictors that identify patients at risk for meningitis from whom cerebrospinal fluid should be obtained?
Level C Recommendations:
(1) Although there are no predictors that adequately identify full-term well-appearing febrile infants aged 29 to 90 days from whom cerebrospinal fluid should be obtained, the performance of a lumbar puncture may still be considered.
(2) In the full-term well-appearing febrile infant aged 29 to 90 days diagnosed with a viral illness, deferment of lumbar puncture is a reasonable option, given the lower risk for meningitis. When lumbar puncture is deferred in the full-term well-appearing febrile infant aged 29 to 90 days, antibiotics should be withheld unless another bacterial source is identified. Admission, close follow-up with the primary care provider, or a return visit for a recheck in the Emergency Department is needed. (Consensus recommendation)
Recommendations offered in this policy are not intended to represent the only diagnostic and management options that the emergency physician should consider. ACEP recognizes the importance of the individual physician's judgment and patient preferences.