1. An Evidence - Based Guideline EVALUATION AND MANAGEMENT of FEVER IN INFANTS

2. The following presentation is part of an educational program for physicians produced by the Division of Pediatric Emergency Medicine of the Morgan-Stanley Children’s Hospital of Columbia University Medical Center. Supported by a grant from the r-baby Foundation.

3. EPIDEMIOLOGY OF SEVERE SEPSIS IN CHILDREN IN THE U.S. > 42,000 Cases 50% < 1 Year Old 50% No PMH 10% Mortality

4. Reducing Infant Mortality From Sepsis ED Prevention Strategy: Bacteremia : The presence of bacteria in the blood of a well-appearing infant Complications of Bacteremia: Serious Bacterial Infections (SBI) Sepsis DIC Shock / Multiple organ failure Death Serious focal infections Bacteremia  SBI ✖

5. Clinical Dilemma All Febrile Infants Presenting to ED

6. Evidence Based Guideline Fever In Infants GOALS Primary : Identify infants at risk for Bacteremia/SBI Secondary : Standardized, Evidence-Based Practice Reduce Unnecessary Testing Decreased ED LOS

7. BUILDING THE GUIDELINE TOGETHER

8. GROUP I (0-28 Days) High Prevalence of SBI/Sepsis (5-17%) Immunocompromised Can’t Limit Infections Appearance and Exam Unreliable Group Age Fever Cutoff Evaluation Disposition I 0-28 Days ≥ 100.4 Full Sepsis Workup (Include LP) Admit

9. GROUP II (29-60 Days) LOW RISK CRITERIA History: Previously healthy Normal behavior and feeding Reliable caretaker / phone access Exam: Well appearing Normal vitals & exam Labs: Blood: WBC ≥ 5,000 and < 15,000 B:N < 0.2 Urine: < 10 WBC/HPF CSF: < 8 WBC/HPF Group Age Cutoff Fever Cutoff Evaluation Disposition II 29-60 Days ≥ 100.4 Full Sepsis Workup Admit Vs. Discharge

10. SUMMARY: GROUPS I AND II Group Age Fever Cutoff Evaluation Disposition I 0-28 Days ≥ 100.4 Full Sepsis Workup (Include LP) Admit II 29-60 Days ≥ 100.4 Full Sepsis Workup Admit Vs. Discharge

11. GROUP III (61-90 Days) 61-90 Days Baby In Transition from Immunodeficient to Immunocompetent Fever Cutoff 100.4 Admit for Focal Infections (LIKE YOUNGER INFANTS) No L-P Unless Clinically Indicated Patients Can Be Discharged (LIKE OLDER INFANTS) Group Age Cutoff Fever Cutoff Evaluation Disposition III 61-90 Days ≥ 100.4 Bacteremia Workup (Blood and Urine) Admit Focal Infection Discharge All Other Patients

12. SUMMARY: GROUPS I, II AND III II 29-60 Days ≥ 100.4 Full Sepsis Workup Admit Vs. Discharge Group Age Fever Cutoff Evaluation Disposition I 0-28 Days ≥ 100.4 Full Sepsis Workup (Include LP) Admit III 61-90 Days ≥ 100.4 Bacteremia Workup (Blood and Urine) Admit Focal Infection Discharge All Other Patients

14. GROUP IV: 3-6 Months History: BOTH height and duration of fever Group Age Cutoff Fever Cutoff Evaluation Disposition IV 3-6 Months ≥ 102.2 Bacteremia Workup (Blood and Urine Only) Discharge Fever < 102.2 Lasting ≥ 4 Days Urine Only

15. GROUP V: ≥ 6 Months Blood Testing Temp ≥ 105 OR ≥ 102.2 for 4 days Urine Testing Only if at risk for UTI or any fever x4 days Group Age Cutoff Fever Cutoff Evaluation Disposition V ≥ 6 Months + Immunized + Good Flu ≥ 105 Blood – All Urine – If Indicated Discharge ≥ 102.2 for 4 Days Fever ≤ 102.2 For 4 Days Urine Only: If Indicated Patients at Risk for UTI Circumcised < 6 Months Uncircumcised < 1 Year Old Girls < 2 Years Old Previous H/O UTI

16. Group Age Fever Cutoff Evaluation Disposition I 0-28 Days ≥ 100.4 Full Sepsis Workup (Include LP) Admit II 29-60 Days ≥ 100.4 Full Sepsis Workup Admit Vs. Discharge III 61-90 Days ≥ 100.4 Bacteremia Workup (Blood and Urine) Admit Focal Infection Discharge All Other Patients IV 3-6 Months ≥ 102.2 Bacteremia Workup (Blood and Urine Only) Discharge Fever < 102.2 Lasting ≥ 4 Says Urine Only V ≥ 6 Months + Immunized + Good Flu ≥ 105 Blood – All Urine – If Indicated Discharge ≥ 102.2 for 4 Days Fever ≤ 102.2 For 4 Days Urine Only: If Indicated