From the Guidelines
The appropriate workup for a well-appearing 3-month-old with fever in the ED includes a complete blood count, blood culture, urinalysis with culture, and consideration of lumbar puncture based on clinical assessment, as recommended by the most recent guidelines 1. The management of a well-appearing 3-month-old with fever in the ED is a complex issue that requires careful consideration of the risk of serious bacterial infection (SBI) and the potential for rapid deterioration.
- Key considerations in the initial assessment include:
- The risk of SBI, which is higher in younger infants, particularly those younger than 28 days
- The potential for rapid deterioration, even in well-appearing infants
- The need for empiric antibiotics in certain cases, such as infants younger than 28 days or those with a high risk of SBI
- The workup for a well-appearing 3-month-old with fever in the ED should include:
- Complete blood count
- Blood culture
- Urinalysis with culture
- Consideration of lumbar puncture based on clinical assessment
- Treatment typically involves empiric antibiotics, with the specific regimen depending on the suspected source of infection and the age of the infant, as outlined in the most recent guidelines 1.
- For example, for a well-appearing 3-month-old with a suspected urinary tract infection, the recommended empiric antibiotic regimen is ceftriaxone (50 mg/kg/dose every 24 hours) 1.
- Close follow-up within 24 hours is essential if the infant is discharged, to ensure that any potential complications are promptly identified and addressed. This approach is necessary because young infants have immature immune systems and can rapidly deteriorate even when initially well-appearing, and because serious bacterial infections like meningitis, bacteremia, and urinary tract infections are more common in this age group than in older children, as highlighted in previous studies 1.
From the FDA Drug Label
CLINICAL STUDIES Clinical Trials in Pediatric Patients With Acute Bacterial Otitis Media The FDA drug label does not answer the question.
From the Research
Evaluation and Management of Febrile Infants
The evaluation and management of a well-appearing 3-month-old with fever in the emergency department (ED) involve a thorough physical examination and laboratory investigations. According to 2, for infants between 1-3 months of age, management may be guided by clinical evaluation and laboratory investigations.
Laboratory Testing
For young febrile children, urine testing is an essential part of the evaluation process. As stated in 3, a strategy of combined urinalysis and urine culture in children with temperature ≥ 39°C is associated with a more favorable risk-benefit profile. However, the decision to perform urine testing should be based on the individual patient's risk factors and clinical presentation.
Urinary Tract Infections (UTIs)
UTIs are a common cause of fever in infants and young children. According to 4, the prevalence of UTI among febrile infants is 5.3%, with white females with rectal temperature ≥ 39°C being at particularly high risk. The diagnosis of UTI can be made using a combination of urinalysis and urine culture.
Treatment of UTIs
The treatment of UTIs in infants and young children depends on the severity of the infection and the patient's clinical presentation. According to 5, infants from 28 days to 3 months of age who appear clinically ill with a febrile UTI should be hospitalized and receive parenteral administration of a 3rd generation cephalosporin or gentamicin. In contrast, infants who are not acutely ill with a febrile UTI may be managed as outpatients with parenteral ceftriaxone or gentamicin and oral antibiotics.
Key Considerations
When evaluating and managing a well-appearing 3-month-old with fever in the ED, the following key considerations should be taken into account:
- A thorough physical examination and laboratory investigations are essential to guide management
- Urine testing should be performed based on individual patient risk factors and clinical presentation
- UTIs are a common cause of fever in infants and young children, and diagnosis can be made using a combination of urinalysis and urine culture
- Treatment of UTIs depends on the severity of the infection and the patient's clinical presentation
- Management may involve hospitalization and parenteral antibiotics for severely ill patients, or outpatient management with oral antibiotics for less severe cases, as discussed in 6.