Pediatric Emergencies — Part 3: Pediatric Sepsis & Febrile Infant Evaluation
Pediatric sepsis recognition with age-specific SIRS criteria, sepsis resuscitation protocol, vasopressor selection, antibiotic guidance, febrile infant risk stratification by age, Rochester-Philadelphia-Boston criteria comparison, PECARN febrile infant rule, and neonatal CSF interpretation.
1. Pediatric Sepsis: Recognition and Definitions
Sepsis remains a leading cause of morbidity and mortality in children worldwide. Early recognition is challenging because children compensate effectively through tachycardia and increased systemic vascular resistance, maintaining blood pressure until late in the course. The transition from compensated to decompensated shock can be precipitous and fatal if not anticipated. A high index of suspicion, use of standardized screening tools, and protocolized treatment bundles have been shown to reduce mortality.1 2
1.1 Age-Specific SIRS Criteria
Systemic inflammatory response syndrome (SIRS) criteria must be age-adjusted in pediatric patients, as normal values for heart rate, respiratory rate, and white blood cell count vary substantially by age. SIRS requires the presence of at least 2 of the following 4 criteria, one of which must be abnormal temperature or abnormal leukocyte count.1
| Age Group | Heart Rate (tachycardia, bpm) | Heart Rate (bradycardia, bpm) | Respiratory Rate (breaths/min) | Leukocyte Count (×10³/mm³) | Systolic BP Hypotension (mmHg) |
|---|---|---|---|---|---|
| Neonate (0–7 days) | >180 | <100 | >50 | >34 or <5 | <59 |
| Neonate (8–28 days) | >180 | <100 | >40 | >19.5 or <5 | <59 |
| Infant (1–12 months) | >180 | <90 | >34 | >17.5 or <5 | <75 |
| Toddler (1–5 years) | >140 | N/A | >22 | >15.5 or <6 | <74 |
| School age (6–12 years) | >130 | N/A | >18 | >13.5 or <4.5 | <83 |
| Adolescent (13–18 years) | >110 | N/A | >14 | >11 or <4.5 | <90 |
Temperature criterion: core temperature >38.5°C (101.3°F) or <36°C (96.8°F)
1.2 Pediatric Sepsis Definitions
| Term | Definition |
|---|---|
| SIRS | ≥2 of 4 age-specific criteria (temperature, heart rate, respiratory rate, WBC), at least one being abnormal temperature or WBC |
| Sepsis | SIRS in the presence of, or as a result of, suspected or proven infection |
| Severe sepsis | Sepsis plus cardiovascular dysfunction, ARDS, or ≥2 other organ dysfunctions |
| Septic shock | Sepsis with cardiovascular dysfunction persisting despite ≥40 mL/kg fluid resuscitation in 1 hour; requires vasoactive medications or manifests as hypotension (age-specific) |
| Refractory shock | Shock persisting despite catecholamine therapy; may be fluid-refractory, catecholamine-resistant, or both |
1.3 Screening Tools
Effective sepsis screening requires integration of vital sign abnormalities with clinical assessment. Key screening elements include:
- Abnormal vital signs (age-adjusted heart rate, respiratory rate, blood pressure, temperature)
- Clinical triggers: altered mental status, capillary refill >3 seconds, mottled skin, weak pulses, decreased urine output, petechial/purpuric rash
- High-risk factors: immunocompromised state, indwelling central line, recent surgery, asplenia, sickle cell disease, age <3 months
- Parental concern: caregiver report that “the child is not acting right” should prompt careful evaluation
- Lactate: venous lactate >2 mmol/L should raise concern; >4 mmol/L is strongly associated with organ dysfunction1 2
2. Pediatric Sepsis Resuscitation
The first hour of sepsis management is critical. The 2020 international pediatric sepsis guidelines emphasize aggressive fluid resuscitation, early antibiotics, and early vasoactive support when fluid-refractory shock is identified.1
2.1 First-Hour Resuscitation Bundle
| Time | Intervention | Details |
|---|---|---|
| 0–5 min | Recognize sepsis | Abnormal vital signs + clinical concern for infection; activate sepsis pathway |
| 0–15 min | Obtain IV/IO access | Two large-bore peripheral IVs; IO if peripheral access fails within 5 minutes (2 attempts) |
| 0–15 min | Obtain labs | Blood culture (before antibiotics when feasible, but do NOT delay antibiotics), CBC, CMP, lactate, VBG, coagulation studies, urinalysis/culture, blood glucose |
| 0–15 min | Administer antibiotics | Broad-spectrum empiric antibiotics within 60 minutes of recognition (ideally within 30 minutes); see antibiotic table below |
| 0–15 min | Begin fluid resuscitation | 20 mL/kg NS or LR bolus over 5-20 minutes (push-pull syringe technique or pressure bag for rapid delivery) |
| 15–30 min | Reassess after each bolus | Heart rate, blood pressure, capillary refill, mental status, urine output |
| 15–60 min | Repeat fluid boluses | Up to 40-60 mL/kg total in the first hour; if ≥40 mL/kg without improvement, the patient has fluid-refractory shock |
| 15–60 min | Start vasoactive agent if fluid-refractory | Epinephrine 0.1-1 mcg/kg/min (cold shock — vasoconstricted, prolonged cap refill, cool extremities) OR Norepinephrine 0.1-2 mcg/kg/min (warm shock — vasodilated, flash cap refill, warm extremities, bounding pulses); may be started peripherally or IO while central access is obtained |
| 0–60 min | Correct hypoglycemia | D10W 2-4 mL/kg IV (neonates); D25W 2-4 mL/kg (infants); D50W 1-2 mL/kg (older children) |
| 0–60 min | Correct hypocalcemia | Calcium chloride 20 mg/kg IV or calcium gluconate 60 mg/kg IV if ionized calcium low |
| 0–60 min | Monitor | Continuous pulse oximetry, telemetry, capnography; place Foley catheter; target urine output ≥1 mL/kg/hr |
2.2 Vasoactive Agent Selection
| Clinical Phenotype | First-Line Agent | Alternative/Add-On | Rationale |
|---|---|---|---|
| Cold shock (vasoconstricted: cool extremities, prolonged cap refill, weak pulses) | Epinephrine 0.1-1 mcg/kg/min | Add vasopressin 0.0003-0.002 units/kg/min (max 0.04 units/min) if refractory | Epinephrine provides inotropy + chronotropy + vasoconstriction; augments cardiac output in low-output state |
| Warm shock (vasodilated: warm extremities, flash cap refill, bounding pulses, wide pulse pressure) | Norepinephrine 0.1-2 mcg/kg/min | Add vasopressin 0.0003-0.002 units/kg/min if refractory; consider phenylephrine | Norepinephrine provides vasoconstriction with some inotropy; restores SVR in vasodilatory state |
| Catecholamine-resistant shock | Add vasopressin | Consider milrinone (0.25-0.75 mcg/kg/min) for low cardiac output; add hydrocortisone | Multi-agent approach targeting different receptor systems |
2.3 Hydrocortisone (Stress-Dose Steroids)
| Indication | Dose | Notes |
|---|---|---|
| Catecholamine-resistant shock | Hydrocortisone 2 mg/kg IV bolus (max 100 mg), then 1-2 mg/kg/day divided q6-8h | Consider in patients requiring escalating vasopressor doses despite adequate fluid resuscitation |
| Known or suspected adrenal insufficiency | Same dosing | History of steroid use, pituitary/adrenal abnormalities, purpura fulminans suggestive of Waterhouse-Friderichsen syndrome |
| Absolute indications | — | Prior chronic steroid use (>14 days in past year); congenital adrenal hyperplasia; hypothalamic-pituitary axis abnormalities |
2.4 Resuscitation Targets
| Parameter | Target |
|---|---|
| Heart rate | Age-appropriate normal range |
| Blood pressure | SBP > 5th percentile for age |
| Capillary refill | ≤2 seconds |
| Mental status | Alert, responsive |
| Urine output | ≥1 mL/kg/hr |
| Lactate | Trending downward; target <2 mmol/L |
| ScvO2 (if central line) | >70% |
| Pulse quality | Strong, equal central and peripheral pulses |
3. Empiric Antibiotic Selection for Pediatric Sepsis
Antibiotic selection depends on patient age, suspected source, local resistance patterns, and immune status. Antibiotics should be administered within 60 minutes of sepsis recognition (ideally within 30 minutes). The following table provides general empiric recommendations; local antibiograms should guide final selection.1 3
3.1 Empiric Antibiotics by Age and Source
| Age / Scenario | Common Pathogens | Empiric Antibiotic Regimen |
|---|---|---|
| 0–28 days (neonate) | Group B Streptococcus, E. coli, Listeria monocytogenes, HSV | Ampicillin 50 mg/kg IV q8h (for GBS and Listeria) + Gentamicin 4-5 mg/kg IV q24h (for gram-negatives); Add Acyclovir 20 mg/kg IV q8h if any HSV risk factors (see section 4.4) |
| 29–60 days | GBS, E. coli, S. pneumoniae, N. meningitidis, S. aureus, enterovirus | Ceftriaxone 50 mg/kg IV q24h (or Cefotaxime 50 mg/kg IV q8h) ± Ampicillin (if Listeria concern); Add Acyclovir if HSV risk factors |
| >60 days, no focus | S. pneumoniae, N. meningitidis, S. aureus, gram-negatives | Ceftriaxone 50-100 mg/kg IV q24h (max 2 g per dose for sepsis, 4 g for meningitis) |
| Suspected meningitis (any age) | Age-dependent (see above) + resistant pneumococcus | Add Vancomycin 15 mg/kg IV q6h to age-appropriate regimen; dexamethasone 0.15 mg/kg IV q6h × 4 days if bacterial meningitis confirmed (ideally given before or with first antibiotic dose) |
| Suspected UTI/pyelonephritis | E. coli, Klebsiella, Proteus, Enterococcus | Ceftriaxone 50 mg/kg IV q24h or Ampicillin + Gentamicin (neonates) |
| Suspected intra-abdominal | Gram-negatives, anaerobes, Enterococcus | Piperacillin-tazobactam 100 mg/kg IV q8h (max 4.5 g) or Ceftriaxone + Metronidazole 10 mg/kg IV q8h (max 500 mg) |
| Suspected skin/soft tissue | S. aureus (MRSA concern), Streptococcus | Vancomycin 15 mg/kg IV q6h + Ceftriaxone if concern for concurrent bacteremia |
| Immunocompromised / neutropenic fever | Broad spectrum including Pseudomonas | Cefepime 50 mg/kg IV q8h (max 2 g) or Meropenem 20 mg/kg IV q8h (max 1 g); add vancomycin if central line or skin/soft tissue concern |
| Toxic shock syndrome | S. aureus, Group A Streptococcus | Vancomycin + Clindamycin 10-13 mg/kg IV q8h (max 900 mg) (clindamycin inhibits toxin production) + broad-spectrum coverage; consider IVIG 1 g/kg × 1 dose |
4. Febrile Infant Evaluation (0–60 Days)
The febrile infant (temperature ≥38.0°C / 100.4°F rectally) aged 0 to 60 days represents one of the highest-stakes evaluations in pediatric emergency medicine. The challenge lies in identifying the small proportion (approximately 5-10%) with serious bacterial infection (SBI: bacteremia, UTI, meningitis) among a population that mostly has benign viral illness but is difficult to assess clinically. Management has evolved from universal admission and full sepsis workups to risk-stratified approaches, though extremely young infants (0-28 days) still warrant a conservative approach.4 5
4.1 Age-Stratified Approach
0–28 Days (Neonates): Full Sepsis Workup and Admission
ALL febrile neonates 0-28 days old (regardless of appearance) should receive:
| Component | Details |
|---|---|
| Complete blood count with differential | WBC count alone has limited sensitivity for SBI in neonates |
| Blood culture | Obtain before antibiotics |
| Urinalysis and urine culture | Catheterized specimen (bag urine unacceptable for culture); positive UA = LE positive or nitrite positive or >10 WBC/hpf |
| Lumbar puncture | CSF cell count, glucose, protein, Gram stain, and culture; CSF HSV PCR if any risk factors; enteroviral PCR during enteroviral season |
| CRP and/or Procalcitonin | Procalcitonin <0.5 ng/mL has high negative predictive value for SBI in neonates >24 hours old; physiologic surge in first 24-48 hours limits utility in the first day of life |
| Chest radiograph | Only if respiratory symptoms present |
| Empiric antibiotics | Ampicillin 50 mg/kg IV q8h + Gentamicin 4-5 mg/kg IV q24h; add Acyclovir 20 mg/kg IV q8h if HSV risk factors |
| Disposition | Admit ALL febrile neonates 0-28 days pending culture results (minimum 24-36 hours); some institutions observe 48-72 hours |
29–60 Days: Risk Stratification
For well-appearing febrile infants aged 29-60 days, the 2021 clinical practice guideline provides a risk-stratified approach based on inflammatory markers and clinical assessment.4
| Step | Action | Details |
|---|---|---|
| 1 | Assess appearance | Use validated illness severity tools; if ill-appearing → full sepsis workup, empiric antibiotics, admission |
| 2 | Obtain urinalysis | Catheterized specimen; if positive → obtain urine culture, blood culture; treat UTI |
| 3 | Obtain inflammatory markers | Procalcitonin (preferred: <0.5 ng/mL is low risk) and/or CRP (<20 mg/L is low risk) and/or ANC (<4,000/mm³ is low risk) |
| 4 | Risk-stratify based on results | See classification below |
| 5 | Decide on LP | Guidelines suggest LP may be deferred in well-appearing 29-60 day old infants with negative inflammatory markers and a positive UA suggesting UTI as the source; LP should be performed if inflammatory markers are elevated, if the infant is ill-appearing, or if antibiotics will be given for concern other than isolated UTI |
Risk Classification for Well-Appearing Febrile Infants 29-60 Days:
| Risk Level | Criteria | Management |
|---|---|---|
| Low risk | Well-appearing AND negative UA AND normal inflammatory markers (PCT <0.5, CRP <20, ANC <4,000) | May observe without antibiotics; can consider discharge home with reliable follow-up in 24 hours IF caregiver is comfortable and has reliable access to care; blood culture should still be obtained; some experts still recommend admission for observation |
| Intermediate risk | Well-appearing AND (positive UA OR mildly elevated inflammatory markers) | Obtain blood culture and urine culture; consider LP; empiric antibiotics (ceftriaxone); admit for observation |
| High risk | Ill-appearing OR significantly elevated inflammatory markers (PCT ≥0.5, CRP ≥20, ANC ≥4,000) | Full sepsis workup including LP; empiric antibiotics; admit |
4.2 Classic Risk Stratification Criteria Comparison
Before the 2021 guideline incorporating procalcitonin, several classic low-risk criteria were developed. They remain useful for understanding the evolution of febrile infant evaluation and for settings where procalcitonin is unavailable.5 6
| Criterion | Age Range | Low-Risk Laboratory Criteria | Low-Risk Clinical Criteria | Additional Requirements | Sensitivity for SBI |
|---|---|---|---|---|---|
| Rochester | 0–60 days | WBC 5,000-15,000; band count <1,500; UA ≤10 WBC/hpf; stool ≤5 WBC/hpf (if diarrhea) | Previously healthy term infant; no focal bacterial infection on exam; appears well | — | ~92% (NPV ~98.9%) |
| Philadelphia | 29–60 days | WBC <15,000; band-to-neutrophil ratio <0.2; UA <10 WBC/hpf; CSF <8 WBC/mm³; negative Gram stain (urine, CSF); negative CXR | Well-appearing | LP required | ~96-100% (NPV ~99%) |
| Boston | 28–89 days | WBC <20,000; CSF <10 WBC/mm³; UA <10 WBC/hpf; CXR no infiltrate (if obtained) | Well-appearing | LP required; empiric IM ceftriaxone given even to low-risk; follow-up at 24 hrs | ~95% (NPV ~94.6%) |
| PECARN Febrile Infant | 29–60 days | UA negative AND procalcitonin <0.5 ng/mL AND ANC <4,090/mm³ | Well-appearing | LP not required if all criteria met; does not apply to 0-28 days | ~97.7% (NPV ~99.6%) |
4.3 PECARN Febrile Infant Rule (29–60 Days)
The Pediatric Emergency Care Applied Research Network (PECARN) febrile infant rule was derived and validated in a prospective cohort of over 1,800 febrile infants aged 29-60 days presenting to pediatric EDs. It identifies a low-risk group with a <1% probability of serious bacterial infection without requiring lumbar puncture.5
Step-by-step application:
- Is the infant well-appearing? → If NO → does not qualify; perform full workup
- Is the urinalysis negative? (LE negative AND nitrite negative AND <5 WBC/hpf on microscopy) → If NO → does not qualify as low-risk for SBI (but source may be UTI)
- Is procalcitonin <0.5 ng/mL? → If NO → does not qualify as low-risk
- Is ANC <4,090/mm³? → If NO → does not qualify as low-risk
- If ALL of the above are YES → Low risk for SBI (0.4% risk of SBI; 0% risk of bacteremia in validation cohort)
PECARN rule does NOT apply to:
- Infants 0-28 days old
- Ill-appearing infants
- Infants with known immunodeficiency
- Preterm infants (<37 weeks gestational age)
- Infants with recent antibiotic use
4.4 HSV Risk Factors and Acyclovir Indications
Neonatal herpes simplex virus (HSV) infection is rare (incidence ~1 in 3,000-20,000 live births) but carries devastating consequences if untreated, with mortality rates of 30% for disseminated disease and 50-70% for CNS disease. Empiric acyclovir should be strongly considered in any febrile neonate with risk factors or compatible clinical findings.7
| HSV Risk Factors — Add Acyclovir | Clinical Findings Suggestive of HSV |
|---|---|
| Maternal history of genital herpes (especially primary infection near delivery) | Vesicular skin lesions (may be absent in up to 40% of neonatal HSV) |
| Vaginal delivery in setting of active maternal lesions | Seizures (especially focal) |
| Age <21 days (peak incidence for neonatal HSV) | CSF pleocytosis with negative bacterial Gram stain |
| Preterm birth | Elevated AST/ALT (disseminated disease) |
| Maternal fever during delivery | Thrombocytopenia or DIC |
| Prolonged rupture of membranes | Ill appearance without clear bacterial source |
| Scalp electrode use | Respiratory failure without clear pulmonary cause |
Acyclovir dosing: 20 mg/kg IV every 8 hours; treatment duration depends on disease classification (SEM: 14 days; CNS or disseminated: 21 days)
4.5 Neonatal CSF Interpretation
CSF interpretation in neonates is complicated by age-dependent normal values. Neonatal CSF normally has higher WBC counts, higher protein, and lower glucose than older children or adults.7
| CSF Parameter | Normal Neonate (0-28 days, term) | Normal Neonate (preterm) | Normal Infant (29-60 days) | Suggestive of Bacterial Meningitis |
|---|---|---|---|---|
| WBC (cells/mm³) | 0-22 (mean ~9) | 0-29 (mean ~9) | 0-9 (mean ~4) | >21 (term neonate); >9 (29-60 days) |
| % Neutrophils | 0-60% | 0-66% | 0-6% | >60% at any age |
| Protein (mg/dL) | 20-170 (mean ~90) | 65-150 (mean ~115) | 20-100 (mean ~60) | >150 (neonate); >100 (29-60 days) |
| Glucose (mg/dL) | 34-119 (mean ~52) | 24-63 (mean ~50) | 40-80 | <34 (neonate); <40 (older infant) |
| CSF:serum glucose ratio | 0.44-2.48 (mean ~0.81) | 0.55-1.05 | 0.6-0.8 | <0.6 |
| Gram stain | No organisms | No organisms | No organisms | Organisms visible (sensitivity 60-90%) |
Key caveats:
- A traumatic LP (≥500 RBC/mm³) complicates WBC interpretation; the commonly used correction formula (subtract 1 WBC per 500-1000 RBC) is unreliable, especially in neonates
- CSF culture remains the gold standard; consider holding antibiotics for 48-72 hours pending culture results if clinical appearance is reassuring
- HSV PCR should be sent on CSF whenever acyclovir is initiated
- Enteroviral PCR is useful during enteroviral season (summer-fall) as enterovirus is the most common cause of aseptic meningitis in young infants4 7
5. Specific Infectious Emergencies in Children
5.1 Meningitis
| Feature | Bacterial | Viral (Aseptic) |
|---|---|---|
| Onset | Rapid, toxic | Gradual, less toxic |
| CSF WBC | >1,000 (often), predominantly neutrophils | 10-500, predominantly lymphocytes |
| CSF glucose | Low (<40 mg/dL) | Normal |
| CSF protein | High (>100 mg/dL) | Normal or mildly elevated |
| Gram stain | Positive in 60-90% | Negative |
| Common organisms | Neonate: GBS, E. coli, Listeria; Child: S. pneumoniae, N. meningitidis; Adolescent: N. meningitidis | Enterovirus (most common), HSV, parechovirus |
5.2 Kawasaki Disease
Kawasaki disease is a medium-vessel vasculitis of unknown etiology that predominantly affects children <5 years old. It is the leading cause of acquired heart disease in children in developed countries. Coronary artery aneurysm development is the most feared complication, occurring in 15-25% of untreated cases and <5% with timely treatment.8
Diagnostic Criteria (Classic Kawasaki):
Fever ≥5 days PLUS ≥4 of the following 5 principal clinical features:
| Feature | Description |
|---|---|
| Bilateral conjunctival injection | Non-exudative; limbal sparing |
| Oral mucosal changes | Erythematous/cracked lips, strawberry tongue, oropharyngeal erythema |
| Peripheral extremity changes | Acute: erythema/edema of hands and feet; Convalescent: periungual desquamation |
| Polymorphous rash | Non-vesicular; often prominent in the groin |
| Cervical lymphadenopathy | ≥1.5 cm diameter, usually unilateral |
Incomplete Kawasaki disease: fever ≥5 days + 2-3 features + laboratory/echocardiographic support → still warrants treatment
Treatment: IVIG 2 g/kg IV over 10-12 hours + aspirin 30-50 mg/kg/day divided q6h (high-dose, until afebrile 48-72 hours) → then 3-5 mg/kg/day (low-dose antiplatelet, for 6-8 weeks minimum or indefinitely if coronary abnormalities)
5.3 Petechiae and Purpura: Approach to the Febrile Child
A febrile child with petechiae or purpura requires urgent evaluation for meningococcemia and other life-threatening infections.2
| Finding | Differential | Urgency |
|---|---|---|
| Petechiae above nipple line only (face, neck) after coughing/vomiting | Mechanical petechiae from increased venous pressure | Low risk if well-appearing, normal vital signs |
| Scattered petechiae + fever + well-appearing | Viral illness (most common), early meningococcemia, ITP, leukemia | Moderate risk — obtain CBC, blood culture, CRP/PCT; observe closely |
| Purpura + fever + ill-appearing | Meningococcemia, DIC, purpura fulminans, Rocky Mountain Spotted Fever | Emergency — immediate IV access, blood cultures, empiric ceftriaxone 100 mg/kg IV (max 2 g); fluid resuscitation |
6. Pediatric Urinary Tract Infection
UTI is the most common serious bacterial infection in febrile infants. Accurate diagnosis requires both a positive urinalysis AND a positive urine culture from a properly collected specimen.9
6.1 Who to Test
| Age | Indication for Urine Testing |
|---|---|
| 0–24 months | All febrile infants without clear source; higher risk in uncircumcised males <6 months, females <24 months, any child with urinary symptoms or prior UTI |
| >24 months | Urinary symptoms (dysuria, frequency, urgency, hematuria, abdominal/flank pain); fever without source; history of recurrent UTI |
6.2 Collection Method
| Method | Acceptability | Notes |
|---|---|---|
| Catheterized specimen | Gold standard in non-toilet-trained | Positive culture: ≥50,000 CFU/mL of a single organism |
| Suprapubic aspiration | Gold standard in neonates | Any growth is significant |
| Clean catch midstream | Acceptable in toilet-trained children | Positive culture: ≥100,000 CFU/mL of a single organism |
| Bag specimen | For UA screening only | Unacceptable for culture (high contamination rate ~63%); negative bag UA has good NPV |
6.3 UA and Culture Interpretation
| UA Finding | Sensitivity | Specificity | Notes |
|---|---|---|---|
| Leukocyte esterase (LE) positive | 79-94% | 72-96% | Most useful single dipstick test |
| Nitrite positive | 15-82% | 90-100% | High specificity but low sensitivity (many pediatric pathogens do not produce nitrite; frequent voiding limits conversion time) |
| Pyuria (>5-10 WBC/hpf) | 73-100% | 81-99% | Standard microscopic criterion |
| Combined (LE + nitrite + microscopy) | >95% | ~90% | Combination testing improves diagnostic accuracy |
6.4 Treatment
| Scenario | Antibiotic | Duration |
|---|---|---|
| Febrile UTI / pyelonephritis (>2 months) | Ceftriaxone 50 mg/kg IV q24h → transition to PO based on sensitivities (cephalexin, amoxicillin-clavulanate, or TMP-SMX) | 7-14 days total |
| Simple cystitis (>2 years) | Cephalexin 25-50 mg/kg/day divided q6-12h, or TMP-SMX 6-12 mg/kg/day (TMP component) divided q12h, or amoxicillin-clavulanate 25-45 mg/kg/day | 3-5 days |
| Neonate | Part of sepsis workup — ampicillin + gentamicin | 7-14 days |
6.5 Imaging After First Febrile UTI
| Imaging | Indication |
|---|---|
| Renal-bladder ultrasound | All children 2-24 months after first febrile UTI; all children with recurrent UTI; atypical UTI (poor response to antibiotics at 48 hours, unusual organism, septicemia) |
| VCUG (voiding cystourethrogram) | NOT routine after first simple febrile UTI; indicated if RBUS is abnormal, recurrent febrile UTI, family history of high-grade VUR, atypical UTI |
| DMSA renal scan | To assess for renal scarring; consider 4-6 months after acute episode in recurrent UTI or known high-grade VUR |
Weiss SL, Peters MJ, Alhazzani W, et al. “Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children.” Pediatr Crit Care Med. 2020;21(2):e52-e106. DOI: 10.1097/PCC.0000000000002198 ↩︎ ↩︎ ↩︎ ↩︎ ↩︎
Davis AL, Carcillo JA, Aneja RK, et al. “American College of Critical Care Medicine Clinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Septic Shock.” Crit Care Med. 2017;45(6):1061-1093. DOI: 10.1097/CCM.0000000000002425 ↩︎ ↩︎ ↩︎
Bradley JS, Byington CL, Shah SS, et al. “The Management of Community-Acquired Pneumonia in Infants and Children Older Than 3 Months of Age: Clinical Practice Guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America.” Clin Infect Dis. 2011;53(7):e25-e76. DOI: 10.1093/cid/cir531 ↩︎
Pantell RH, Roberts KB, Adams WG, et al. “Evaluation and Management of Well-Appearing Febrile Infants 8 to 60 Days Old.” Pediatrics. 2021;148(2):e2021052228. DOI: 10.1542/peds.2021-052228 ↩︎ ↩︎ ↩︎
Kuppermann N, Dayan PS, Levine DA, et al. “A Clinical Prediction Rule to Identify Febrile Infants 60 Days and Younger at Low Risk for Serious Bacterial Infections.” JAMA Pediatr. 2019;173(4):342-351. DOI: 10.1001/jamapediatrics.2018.5501 ↩︎ ↩︎ ↩︎
Jaskiewicz JA, McCarthy CA, Richardson AC, et al. “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. DOI: 10.1542/peds.94.3.390 ↩︎
Kimberlin DW, Baley J, Committee on Infectious Diseases, Committee on Fetus and Newborn. “Guidance on Management of Asymptomatic Neonates Born to Women with Active Genital Herpes Lesions.” Pediatrics. 2013;131(2):e572-e578. DOI: 10.1542/peds.2012-3216 ↩︎ ↩︎ ↩︎
McCrindle BW, Rowley AH, Newburger JW, et al. “Diagnosis, Treatment, and Long-Term Management of Kawasaki Disease: A Scientific Statement for Health Professionals From the American Heart Association.” Circulation. 2017;135(17):e927-e999. DOI: 10.1161/CIR.0000000000000484 ↩︎
Roberts KB, Subcommittee on Urinary Tract Infection. “Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months.” Pediatrics. 2011;128(3):595-610. DOI: 10.1542/peds.2011-1330 ↩︎