Journal Club

New Data to Answer an Old Question: What to Do with the Febrile Infant?

By Terri Stillwell, MD

The management of the well-appearing febrile neonate is a near daily question for pediatricians and infectious diseases specialists alike. As with many things, variations in practice exist. A new evaluation and management guideline from the American Academy of Pediatrics, recently published in Pediatrics, offers an updated approach.

Using an evidence and literature review set forth by the Agency for Healthcare Research and Quality and taking into account the shift in microbiologic epidemiology of infections and advances in diagnostic abilities, the authoring committee created recommendations targeting the well-appearing, full-term, otherwise healthy febrile infant, aged 8 to 60 days old. The guideline’s primary focus is the diagnosis and treatment of bacterial infections (urinary tract infections, bacteremia, and meningitis).

End users should make sure to read the guideline in full, as there are several caveats regarding when not to apply these recommendations as well as very nuanced recommendations based on various clinical scenarios. One of the bigger paradigm shifts is that the guideline excludes patients less than a week old and has a new carve out for patients 22 to 28 days of age, presenting three age-based algorithms. The guideline also incorporates the use of inflammatory markers into the decision tree, particularly for older infants; offers guidance regarding when a lumbar puncture should be performed; recommends when antibiotics should be started, including caveats for when oral antibiotics may be suitable; and provides guidance for potential earlier discontinuation of antibiotics and discharge to home.

This clinical practice guideline offers a new approach to the well-appearing febrile infant, using the most up-to-date literature to inform the guidance. As with any patient, decision making should be tailored to the individual patient, based on their clinical presentation.

(Pantell et al. Pediatrics. 2021;148:e2021052228.)