Approach to fever without a source in children 3 to 36 months of age, either unimmunized or incompletely immunized

This algorithm provides guidance for unimmunized or incompletely immunized children 3 to 36 months of age who have fever without a source. Incomplete immunization means that the child has not received the primary series of pneumococcal and Haemophilus influenzae, type b conjugate vaccines. This definition includes all children <6 months old. However, some experts consider two doses of pneumococcal conjugate vaccine sufficient to prevent invasive pneumococcal infection. For more information, refer to UpToDate on the evaluation and management of infants and young children with fever and no obvious source.

ANC: absolute neutrophil count; CBC: complete blood count; COVID-19: coronavirus disease 2019; HPF: high-power field; LE: leukocyte esterase; URI: upper respiratory infection; UTI: urinary tract infection; WBC: white blood cell.

* 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.

¶ To avoid multiple blood draws, the blood culture may be drawn with the CBC and sent if the 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.

Δ Refer to UpToDate content on empiric treatment of UTI in children.

◊ 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.

Graphic 121480 Version 4.0

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Approach to fever without a source in children 3 to 36 months of age, either unimmunized or incompletely immunized