Pediatric Fever Protocols

There have been several attempts at building protocols for pediatric fever in order to determine what children 3 months and younger can be discharged home. The most commonly used protocols include the Rochester, Philadelphia, and now Step-by-Step. Although there is an exceptional comparison of these protocols (Step by Step not included) from Hui et al in 2012, the most important point to remember is that all of these protocols perform similarly. It is better to use any single one of them, than to use none.

Calculators exist for the Step-By-Step and Rochester protocols at MDcalc. In addition, there is an excellent EMRAP C3 episode on the subject. Links below.

Step By Step < 90 days

Criteria:
  • Previously healthy
  • Fever > 38 C (100.4 F) in ED or at home
    • Performs better when fever duration is > 2 hrs
  • No prior illness includes
    • born term (37 weeks)
    • No unexplained hyperbilirubinemia
    • No prior hospitalizations
    • No chronic illness
    • Not hospitalized longer than mother after delivery
  • No perinatal antibiotics
  • Infants <22 days old considered high risk
    • Full sepsis workup (labs, urine, LP)
    • Initiate antibiotics
    • Admission

Testing:

  • Labs
    • Leukocyturia must be absent
    • Procalcitonin <0.5 ng/ml
    • CRP < 20 mg/L or ANC < 10K mm2
Interpretation:
  • All criteria met = Low Risk
    • 0.7% risk of invasive bacterial infection
    • discharge home, no antibiotics
  • All criteria except CRP/ANC met = Intermediate Risk
    • 3.4 % risk of invasive bacterial infection
    • Obtain cultures, labs, CSF
    • Administer antibiotics
    • Admission may be necessary
  • All others = high risk
    • 8.1 % risk of invasive bacterial infection
    • Obtain cultures, labs, CSF, CXR
    • Administer antibiotics
    • Admission
  • Sensitivity 92%, NPV 99.3%, low specificity for IBI meaning failure to meet low risk criteria doesn’t mean IBI is present.
  • Note: 4 of 7 patients with IBI missed in the validation trial were between 21-28 days old. Recommendations from others, after validation have been to continue aggressively testing, treating, and admitting patients < 28 days old.

Rochester Criteria 60 days

Criteria:
  • Appears well
  • Fever 38 C (100.4 F) in ED or at home
  • No source of focal infection
  • No prior illness includes
  • Born term (37 weeks)
  • No perinatal antibiotics
  • No unexplained hyperbilirubinemia
  • No prior hospitalizations
  • No chronic illness
  • Not hospitalized longer than mother after delivery
Testing:
  • Labs
  • WBC 5k-15k
  • Bands < 1.5k
  • Fecal leukocytes < 5 wbc/hpf (if diarrhea present)
  • Urine wbc < 10/hpf
Interpretation:
  • All criteria met = low risk for SBI
  • <1% risk of SBI
  • Obtain cultures,
  • No antibiotics
  • Close follow up
  • All criteria NOT met = NOT low risk
  • Obtain cultures
  • Give antibiotics
  • Admit
  • NPV 93-100%, Sensitivity 91-100% (Hui)

Philadelphia Criteria 29-56 days

Criteria:
  • Appears well
  • Rectal temp > 38.2 C (100.76 F)
Testing:
  • Labs
  • WBC < 15k
  • Band to neutrophil ratio <0.2
  • Urine wbc <10/hpf
  • Urine gram stain negative
  • CSF < 8 wbc/mm3
  • CSF gram stain negative
  • CXR negative (if obtained)
  • Stool negative blood and “few to no” fecal leukocytes, if obtained
Interpretation:
  • All criteria met = low risk
    • Short term outpatient follow up (24-48 hrs)
    • No antibiotics
  • All criteria NOT met = high risk
    • Give antibiotics
    • Admission
  • NPV 95-100%, Sensitivity 98-100%

References:

MDCalc Step-By-Step , Rochester

Step by Step:
  • Gomez B, Mintegi S, Bressan S, et al. Validation of the “Step-by-Step” Approach in the Management of Young Febrile Infants. Pediatrics. 2016;138(2)  Download PDF
  • Aronson PL, Neuman MI. Should We Evaluate Febrile Young Infants Step-by-Step in the Emergency Department?. Pediatrics. 2016;138(2) Download PDF
Rochester:
  • Jaskiewicz JA, McCarthy CA, Richardson AC, et al; Febrile Infant Collaborative Study Group. Febrile infants at low risk for serious bacterial infection—an appraisal of the Rochester criteria and implications for management. Pediatrics. 1994;94(3):390–396  PubMed
Philadelphia:
  • Baker MD, Bell LM, Avner JR. Outpatient management without antibiotics of fever in selected infants. N Engl J Med. 1993;329(20):1437–1441 PubMed
Comparison:
  • Hui C, Neto G, Tsertsvadze A, et al. Diagnosis and management of febrile infants (0-3 months). Evid Rep Technol Assess (Full Rep). 2012;(205):1–297 PubMed

EMRAP:

  • Pediatric Fever 29-56 days, C3 episode Podcast
  • Pediatric Fever 57-89 days, C3 episode Podcast

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