Emergency department evaluation and management of fever without a source in children 3 to 36 months of age, either unimmunized or incompletely immunized

ANC: absolute neutrophil count; CBC: complete blood count; LE: leukocyte esterase; PCT: procalcitonin; UTI: urinary tract infection; WBC: white blood cell count.

* For patients with acute suppurative otitis media who will receive recommended antibiotic therapy effective against common bacterial otopathogens that address current patterns of resistance, evaluation for occult bacteremia is not routinely necessary.

¶ If results are rapidly available (eg, within 60 minutes), a serum procalcitonin level identifies invasive bacterial illness with higher sensitivity and specificity than WBC or ANC. A procalcitonin level >0.5 ng/mL warrants the same management as a WBC ≥15,000/microL or an ANC ≥10,000/microL. Refer to UpToDate topics on fever without a source in children 3 to 36 months of age.

Δ To avoid multiple blood draws, the blood culture may be drawn with the CBC and sent if the PCT, WBC, or ANC is elevated. Recognizing that these studies are not ideal screening tools, some clinicians may prefer to always send a blood culture in these patients.

◊ Young children at increased risk for UTI include:

• Females <24 months old
• Circumsized males <6 months old
• Uncircumcised males <12 months old
• Prior history of UTI
• Known urogenital anomalies,
• Prolonged fever (>48 hours)
• Signs or symptoms of UTI (any one of the following: dysuria, frequency, abdominal pain, back pain, or new-onset incontinence)

If bag urine specimens show a normal urine dip or urinalysis, then a urine culture is not necessary.

§ Refer to UpToDate content on empiric treatment of UTI in children. Consider chest radiograph for children with WBC >20,000/microL.

¥ Ceftriaxone (50 mg/kg, intramuscularly) is preferred because of its antimicrobial spectrum and prolonged duration of action. Refer to UpToDate content on treatment of children with fever without a source.