Fever and Sepsis Evaluation in the Infant (Ages 29-60 days)

Pathway Background and Objectives

Fever is a common reason for visits to the Emergency Department (ED) and for admission to the hospital. Nationally, there are 500,000 ED visits annually for children ≤ 60 days of age with fever. Though most febrile illnesses in infants less than 90 days of age are caused by viral infections, 6-10% of febrile illnesses in this age group are a result of serious bacterial infections (SBI). This rate is higher than the general population. The incidence of specific SBIs in this age group are: urinary tract infection (5-9%), bacteremia (1.9-2.2%), meningitis (0.3-0.5%), and other less common diagnoses (e.g. pneumonia, skin and soft tissue infection, osteomyelitis). There is great variability in care provided to patients in this age group nationally, and prior to this pathway implementation, there was similar variability at our institution. Past management of febrile infants ages 29-60 days was guided by 3 common algorithms: Philadelphia Criteria, Rochester Criteria, and Boston Criteria. However, more and more evidence now exists which supports the following changes in management: use of clinical pathways for workup and treatment of these infants, decreasing the rate of lumbar punctures (LPs) performed on well appearing infants, and shorter length of stay and earlier discontinuation of antibiotics if hospitalized. These practices are now additionally supported by the new 2021 American Academy of Pediatrics Clinical Practice Guideline for the Evaluation and Management of Well-Appearing Febrile Infants 8 to 60 Days Old. The objectives of this pathway are to:

  • Decrease variability in care for febrile infants ages 29-60 days
  • Decrease unnecessary testing
  • Decrease unnecessary antibiotic use
  • Decrease rate of hospitalization for well-appearing infants with low risk test results
  • Decrease average length of stay of patients admitted as inpatient or placed in observation
     

Algorithm  Educational Module

  • Percentage of eligible patients treated per pathway
  • Percentage of patients with order set usage
  • Percentage of patients for whom recommendations for lumbar puncture followed
  • Percentage of patients for whom recommendations regarding antimicrobials followed
  • Average length of stay for ED patients
  • Average length of stay for inpatient and observation patients (excluding those with positive cultures)
  • Returns to ED within 2 days due to a positive culture
  • Readmissions within 2 days due to a positive culture

*Stratifying all metrics into 2 groups: positive and negative viral testing (for influenza, RSV, COVID-19)

  • Eric Hoppa, MD
  • Ilana Waynik, MD

The clinical pathways in the above links have been developed specifically for use at Connecticut Children’s and are made available publicly for informational and/or educational purposes only. The clinical pathways are not intended to be, nor are they, a substitute for individualized professional medical judgment, advice, diagnosis, or treatment. Although Connecticut Children’s makes all efforts to ensure the accuracy of the posted content, Connecticut Children’s makes no warranty of any kind as to the accuracy or completeness of the information or its fitness for use at any particular facility or in any individual case.