Fever Without a Source - neonate

Authors: Hemal Kanzaria, MD, Christine Cho, MD, Andi Marmor, MD, Ellen Laves, MD

Updated: 2/2/2012

Pediatric Fever Without a Source: Birth - 28 Days Old

Age ≤ 28 days (be more conservative for premature infants)
Fever defined as temperature ≥ 38°C / 100.4°F (rectal)
Viral URI symptoms do NOT count as a fever source in this age group.
Disposition: ADMIT all of these patients to the hospital.

Background

History and physical are not reliable to rule-out serious bacterial infection (SBI)

12-28% of febrile neonates have SBI, and a high rate of missed SBIs exist. (Ishimine, EM Clin N Am 2007)

Common causes for SBI

UTIs 20%
Bacteremia 3%
Meningitis 1%

Other causes for SBI’s

Bacterial gastroenteritis
Gonococcal keratoconjunctivitis
Omphalitis
Osteomyelitis
Peritonitis
Pneumonia
Septic joint

Pathogens

More common:
- E. coli
- Group B Strep
- HSV
Less common:
- Listeria
- Salmonella
- Staph aureus

Workup

CBC with differential
Blood cultures
Catheterized urinalysis and urine culture (or via suprapubic tap)
CSF studies (cell count, glucose, protein, gram stain, culture, extra tube to hold for potential other studies)
Consider: Stool culture (if diarrhea)
Consider: CXR and rapid viral testing (if respiratory sx or increased work of breathing, although viral testing should not change sepsis workup)

Treatment

Timely administration of IV antibiotics (ampicillin + cefotaxime, or ampicillin + gentamicin).

May give IM, if IV not possible
Cefotaxime more consistently absorbed IM than gentamicin.

Add acyclovir, if any 1 of following:

Ill-appearing
Skin or mucosal lesions consistent with HSV (i.e. vesicles)
CSF pleocytosis
Seizure
Focal neurologic signs
Abnormal neuroimaging
Respiratory distress, apnea, or progressive pneumonitis
Thrombocytopenia
Elevated liver transaminases, viral hepatitis, or acute liver failure
Conjunctivitis, excessive tearing, or painful eye symptoms

Note: Disseminated HSV and HSV encephalitis may not present with rash

References

Ishimine P, The evolving approach to the young child who has fever and no obvious source. Emerg Med Clin North Am. 2007 Nov;25(4):1087-115, vii. [PubMed]