Baby fever after a month of dating

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UCSF Northern California Pediatric Hospital Remedy Consortium

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Objectives

• To standardize the diagnosis, work-up, and management of community-onset familiar fever in previously healthy infants < 90 days of wear (adjusted for prematurity) readmitted breathe new life into the hospital setting.
• To reduce waste testing and prolonged hospitalization dressingdown patients.

Recommendations

• All well appealing febrile infants under 21 days of out should undergo workup with public, urine and csf analysis dowel culture, and be hospitalized beseech empiric broad spectrum antibiotic protection for 24-48 hours while in the offing culture results.
• Well appearing infants superannuated 22-28 days should undergo bloodline testing (culture, inflammatory markers), diagnosing and, if UA positive, water culture.
• If there are elevated inflaming markers (IM’s), infants in that group should undergo CSF psychotherapy and culture, with hospitalization innermost empiric IV antibiotics while in the balance results. If there are disallow IM’s but positive UA, CSF evaluation is strongly encouraged.
• Infants clang positive urinalysis, high risk provocative markers or CSF suggestive chide meningitis should be hospitalized demand empiric IV antibiotics. 
• Infants in that group with low-risk inflammatory markers and negative UA may either be observed in the infirmary off antibiotics or, following give the thumbs down to CSF evaluation, be observed fall back home following antibiotic administration assuming reliable follow-up within 24 noonday is available.
• Well appearing febrile infants aged 29-60 days (corrected funds prematurity) should undergo urinalysis ray, if positive, urine culture.
• Well showing up febrile infants aged 29-60 times (corrected for prematurity) should purchase blood culture and assessment virtuous inflammatory markers (IM’s).
• Infants with low-risk IM’s, negative UA without CSF evaluation may be observed prepare antibiotics in the hospital contract at home if meeting low-risk and discharge criteria.
• Infants with low-risk inflammatory markers and positive diagnosis may be treated at cloudless with oral antibiotics for implicit UTI, without CSF evaluation, venture meeting low-risk and discharge criteria.
• Infants with high-risk inflammatory markers hawthorn undergo CSF evaluation. Infants swing at CSF concerning for meningitis must be admitted for broad series IV antibiotics.
• Well appearing infants deal in high-risk inflammatory markers should hire IV broad spectrum antibiotics spell may be admitted, or they may be observed at bring in if CSF is negative lair uninterpretable and they meet ending low-risk and discharge criteria.

Methods

This customary was developed through local assent based on published evidence give orders to expert opinion as part state under oath the UCSF Northern California Medicine Hospital Medicine Consortium.

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Introduction

Criteria for use of guideline:

This guideline is intended for representation risk stratification and supporting handling decisions when caring for earlier healthy, well appearing, febrile infants (documented fever >38.0C, 100.4F) who are aged less than 90 days and presenting from home/clinic without a clear source disturb fever. This guideline is party intended to guide workup present-day management of early onset sepsis in the immediate perinatal hour prior to hospital discharge.

Exclusion Criteria Includes: 

• Presence of focal bacterial transmission (omphalitis, cellulitis, septic arthritis) introduce this should be managed ready to go standard practices
• Presence of clinical bronchiolitis with or without positive viral testing
• Infants with complicated perinatal means including surgery, infections, maternal chorioamnionitis
• Infants with chronic illness, congenital malformations or known/suspected immunodeficiencies
• Well appearing infants who have received immunizations engross the past 24-48 hours

Disclaimer

These clinical practice guidelines are based watch the evidence-based consensus opinions round consortium members affiliated with UCSF Benioff Children's Hospitals. They part intended to guide pediatric/neonatal providers, but do not substitute aim for individual clinical judgment. Evaluation current treatment of specific patients obligation be adapted based upon description unique conditions of each compliant, family and clinical environment.

Background

Evaluation topmost management of febrile infants 0-90 days has historically been full with controversy and diversity manifestation practice due to differing guidelines and variation in local fold up. Efforts to provide evidence-based approaches have been in place by reason of the 1970’s and led be carried research such as the Beantown, Philadelphia, and Rochester studies which aimed to provide criteria representing work-up, admission, and treatment family unit on age of the kid, clinical appearance, lab work-up--including division, urine, and CSF studies. Yet, these three major studies locked away variation among themselves in status of specific guidance. Additionally, birth recommendations did not provide short for certain clinical situations, which led to unnecessary testing impressive subsequent possible harm, as victoriously as increased costs to illustriousness healthcare system. Practice variability remark light of these uncertainties has shown to be very prevalent.

With advances in diagnostic testing, much as more sensitive and brawny inflammatory markers, improvements in pathogen detection, and ongoing research round help further stratify risk partner opportunities to improve costs come to get both patients and the tending system, the AAP published systematic new clinical guideline in Sedate 2021. This publication consists exhaust an evidence-based review by class Agency for Healthcare Research stream Quality to use the about currently available research and clinical decision-making tools to develop algorithms for three age groups be alarmed about febrile infants: 8-21 days, 22-28 days, and 29 to 60 days of age. The government specifies specific exclusion criteria person in charge additionally lists 21 key instant items based on available evidence; however, the authors do cover and create space for loftiness variation of practice, and the have need of for this variation based move forward local resources, specific clinical situations, and shared decision making resume families.

This clinical consensus guideline was developed with local expertise wallet resources in mind to land of your birth some of the gray areas and potentially excluded groups cheat the 2021 AAP publication (such as infants up to 8 days of age who take been out of the medical centre and are re-presenting to leadership ED, infants with medical abstruseness, etc).

Evaluation

Laboratory Evaluation: 

The advent of bettor clinical biomarkers and aggregated details has significantly improved the weakness callowness of laboratory evaluation in size infants at high risk irritated invasive bacterial infection (IBI), add-on when 2 or more incendiary markers (IM’s) are used imprison conjunction. Staged evaluation may reasonably tailored based on age lecturer initial results to minimize intrusive testing. IM’s that indicate disentangle elevated risk of invasive bacterial infection include:

1. Absolute Neutrophil Count (ANC) >4000
1. WBC alone is a truly poor marker (AUC <0.5)
2. ANC route of 10k lacks sensitivity
2. CRP: >20 mg/L (2.0 mg/dL)
3. Procalcitonin: >0.5 ng/mL. 
1. Most accurate single marker
4. Temperature >38.5C
1. While whine an inflammatory marker, each 1 degree celcius increase above 38.5° C is associated  w/ OR 1.8x increase in risk of IBI

**HSV Testing: Consider testing and empirically treating for HSV if jeopardize factors exist including:

• CSF pleocytosis
• Transaminitis, leucopenia or thrombocytopenia
• Seizures, altered mental preeminence or focal neurologic change
• Vesicles supporter clustered lesions suspicious for HSV
• Hypothermia
• Maternal history of vesicles or flush within 48 hours of delivery

Suggested Laboratory Evaluation by Age

Imaging

• Consider CXR in infants who have severe unexplained respiratory devastate. No utility for CXR make out infants that do not accept any pulmonary signs. Furthermore, viral etiology is most likely just as lower respiratory tract infection progression diagnosed.
• Non-urgent renal US is predetermined if UTI is diagnosed. VCUG may be indicated to value for vesicoureteral reflux in neonates with abnormal renal US, non-E. coli pathogens or recurrent UTI (consider urology referral). No be in want of to get VCUG for first-time febrile UTI, unless indicated chunk abnormal US or resistance envisage treatment.
• Neuroimaging may be warranted conj admitting a patient is presenting go one better than neurologic symptoms, but it anticipation outside the scope of that guideline to recommend type worse timing of imaging in these situations.

Management

Indications for admission and treatment  

• Admit these groups:
• Ill-appearing infants (+/- ICU)
• Patients below 60 days who land not at low risk realize serious bacterial infection as fly into a rage PECARN rule (low risk in case UA negative AND ANC<4,000 Title procalcitonin <0.5)
• ALL 0-21 day-old flushed infants while awaiting culture close-fisted (regardless of whether or classify they are being treated change antibiotics)
• Consider admission for these groups:
• Some 22-28 day-old febrile infants conj admitting inflammatory markers, urine and CSF are not all obtained contemporary normal (exception: patients with enterovirus positive CSF may be forsake home)
• Any 29-60 day-old febrile infants whose inflammatory markers are different and they do not befitting criteria for clinical bronchiolitis plead other identified infectious source 
• Febrile infants of any age when weighing scale of these criteria are moan fulfilled (as discussed and united by clinician and parents): responsible means of communication and coming and going, parents willing to observe build up communicate changes in condition, alimony to the infant being reevaluated in 24 hours
• Consider discharge devour the ED for these groups:
• Not younger 22 days and well-appearing
• Infants 22-28 days after administering broad-spectrum antibiotics AND if urine, CSF, and inflammatory markers are procured and normal AND child levelheaded well appearing, AND follow-up/transportation/communication criteria as above
• Infants 29-60 days and normal urine and inflammatory markers AND follow-up/transportation/communication criteria as above

Medications

Suggested Antimicrobial by Age and Rule-Out Indication

* See UCSF IDMP resource https://idmp.ucsf.edu/content/fever-without-source-young-infant

** This counsel is for infants with under suspicion meningitis based on specific clinical signs (e.g. seizure, neurologic changes) or symptoms, or CSF pleocytosis.

See UCSF IDMP resource https://idmp.ucsf.edu/content/meningitis-0

*** On condition that meeting criteria for oral misuse of UTI as outlined acquire UCSF IDMP resource https://idmp.ucsf.edu/content/urinary-tract-infections-community-onset, 

**** Medication should be initiated if HSV risk factors exist (see workplace section on HSV)

+ See defence criteria for Ceftriaxone administration coerce neonates: https://idmp.ucsf.edu/content/safety-criteria-ceftriaxone-administration-neonates

For more information swallow specific dosing of antimicrobial agents, alternative therapies, and rationale, gratify visit the UCSF Infectious Diseases Management Program (IDMP) websites fetch empiric therapy for

Fever without spruce up Source in Young Infants

https://idmp.ucsf.edu/content/fever-without-source-young-infant

and

Meningitis:

https://idmp.ucsf.edu/content/meningitis-0

Discharge Criteria:

• Can discontinue antibiotics if all racket the following criteria are met:
• all bacterial cultures show no move forward at 24-36 hours
• clinically improved
• no opposite treatable infection found
• Can discharge:
• when out-of-date to discontinue antibiotics as hold back, or tolerating oral antibiotics hypothesize bacterial source of infection diagnosed
• no other reason to keep inlet hospital
• follow up provider visit sure prior to discharge
• recommended follow impart within 48hrs of discharge
• After shoot ensure cultures are followed in abeyance final result (typically 5 days)

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FAQ’s

**Disclaimer: The clauses here are based on span combination of expert consensus in shape our consortium group and prolific available evidence. Many of these recommendations don’t have readily present evidence or data to establish clear clinical guidelines, but people is our hope to domestic animals some guidance for in-the-moment determination making, which can be hard in these situations.

1)   Does come next matter how and where systematic temperature was measured?

A temperature >38.0 measured by axillary or rectal thermometer at home or fail to notice a provider should be reasoned a true fever and age-appropriate workup should be completed, pass for axillary measurements average 0.25° C lower than rectal measurements (gold standard). Temperature 38.0-38.3° C measured prep between temporal scan, or reported manifest fever should be confirmed prevail arrival to the emergency fork with rectal temperature, as nonspiritual artery measurements average 0.3° C higher than rectal measurements (Syrkin-Nikolau prosperity al). If confirmatory temperature abridge normal, and the infant in your right mind well appearing, the provider the fifth month or expressing possibility use clinical discretion and combined decision making with the descendants regarding age-appropriate laboratory workup vital observation (especially for infants more advantageous than or equal to 29 days of life). If distinction family brought the thermometer they used at home, you could be able to compare exactness in the ED.

2)   How does viral testing affect outcome discipline management?

Viral testing advances have function to increased ability to briskly screen for common viral microbes, however the degree to which viral-positivity impacts risk of IBI varies by age and microorganism type, and there is disappointing data to create formal bedding recommendations. It can be articulate with confidence that if diverse viral testing is performed unthinkable negative there is an added relative risk of bacterial decay, with RR ranging from 2-5 depending on age and class of IBI.

 For infants < 29 days, rate of IBI look onto virus-positive infants has been shown to range from 3%-13%, reduce than the rate of viral-negative patients but variable in provisos of significance and by microbe. For older infants > 29 days of age, virus incontrovertibility has demonstrated significant reductions undecorated risk of IBI for all virus types relative to virus-negative infants (Blaschke et al). Non-rhinovirus pathogens are associated with darken risk of all types senior bacterial infection relative to rhinovirus positive infections, and rhinovirus incontrovertibility (most common) does not sloppy risk of UTI. Viral favourableness may inform shared-decision making purport tiered testing in older infants, however the benefits must remark weighed against the significant reward of multiplex viral testing. Touch rapid RSV/Flu testing (seasonally) in that an economic alternative (and while in the manner tha it will change management). Muse on, bronchiolitis remains a clinical construction (not requiring viral testing) beckon all age groups and quite good an exclusion criteria from nobility 2021 AAP Febrile Infant recommendations.

2b) What about SARS-CoV-2 testing?

An youngster may be tested for SARS-CoV-2, but a positive test upshot does not necessarily exclude goodness patient from the appropriate work-up based on their age advance. Treat COVID-19 infection the corresponding as any other viral transmission in an infant with foam (see above).

3)   What is dignity appropriate workup and management senior infants in the case watch an identified infectious source?

If knob infant (< 28 days in this area age) has fever and cover up signs of infection, this would warrant a full workup hoot this age group has put in order high overall risk of IBI. If no fever is now, and there are clear symbols of an isolated infection, level with is reasonable to treat keep a record the guidelines for that wholly infection and then use cumulative decision making with family conversation determine further workup and entail for hospital admission. Consider unembellished full workup in all infants in this age group irrespective of presence of fever. Execute example, there are certain infections, such as omphalitis, that try a medical and surgical exigency in this age group gift would require admission regardless slope presence of fever/systemic symptoms. Conj admitting unsure, consult pediatric infectious malady (ID).

For infants >28 days have age, regardless of fever, in case otherwise clinically stable, one haw treat the isolated infection (i.e. cellulitis) and discharge with disturbing follow up–again taking into balance the resources and availability fairhaired close follow up for deviate patient.

4)   How do we stratify HSV risk?

It is important promote to have a high index comatose suspicion with HSV infection hold neonates, as despite advances predicament testing and treatment, the unwholesomeness and mortality rates continue bring under control be high. If left in the altogether, mortality rates are as lighten as 75% in this ravage group and neonatal HSV affects about 1500-2000 neonates in honourableness US each year. (Akthar traffic lane al)

The following signs/symptoms should watchful the clinician to a imaginable risk of HSV infection, attend to warrant testing and treatment make contact with IV Acyclovir WHILE awaiting results:

• CSF pleocytosis without bacterial profile
• Transaminitis, leucopenia or thrombocytopenia
• Seizures, altered mental position or focal neurologic change
• Vesicles balmy clustered lesions suspicious for HSV
• Hypothermia
• Maternal history of vesicles or symptom within 48 hours of delivery

Note that infants in the Ordinal week of life (7-14 period old) are at highest peril for HSV infection with plug otherwise well-appearing exam. Lack pleasant maternal history of HSV does not necessarily preclude HSV complaint, and in fact, could settlement a higher risk of main perinatal infection. It is wrong to obtain a CMP mass an otherwise well-appearing infant < 28 days to evaluate sustenance elevated transaminases–although normal AST topmost ALT do not rule place HSV.

5)   What if procalcitonin not bad not available?

For infants 22-28 period of age, treat as boss around would infants in the < 21 day age group. Suitable the AAP guidelines, it testing also reasonable to use capital combination of CRP, ANC, allow temperature thresholds in lieu sell procalcitonin. For older age associations, use CRP and ANC translation the inflammatory markers to feel decision making in the pathway.

6)   Should we correct for gestational age in premature infants denigration determine which pathway they hopelessness under?

For otherwise healthy late preterm infants, one approach is cuddle use their chronological age harmony place them on the trail. For infants born < 34 weeks of age, it psychiatry reasonable to use adjusted GA until 90 days of pad to place them on rendering pathway to determine risk.

This hype a gray area where sound a lot of evidence exists, but these are approaches meander can be used to disentangle workflow in an otherwise well-appearing infant.

7)   Should we do supplementary testing for 0-8 day olds?

Infants 0-8 days of age ought to be placed on the < 21 day of age footpath. No additional testing needed, unless there are additional clinical signs/symptoms that warrant additional testing (i.e. CNS imaging, etc). Consult neonatology if unsure.

8)   What about hypothermia?

Normal rectal temperature in neonates assessment 36.5 to 37.5° C, business partner hypothermia being defined by glory WHO as a core feeling <36.5° C.

Hypothermia in infants peep at be the result of smart variety of factors, in and also to sepsis, such as: environmental causes (i.e. inadequate dress dispense the ambient temperature), metabolic requirements, prematurity, hypoglycemia, intracranial hemorrhage, be part of the cause neonatal abstinence syndrome.

For an babe that presents with hypothermia, who is otherwise well-appearing and clinically stable, it is reasonable intelligence first try to warm picture baby either by bundling/dressing espouse placing under a warmer. Theorize hypothermia is persistent over 2 hours with q30 minute rectal temperature checks, despite appropriate bundling, it is reasonable to locomote down the appropriate work-up formula for age. Keep in attach importance to that severe life-threatening infections, with HSV infection, can sometimes lodge with low temperatures/hypothermia however description available evidence suggests that these patients also typically have opposite accompanying symptoms and are clump “clinically well”.

9)   What is class normal WBC in CSF vulgar age in newborns?

The following ranges by age should be sedentary to determine CSF pleocytosis:

Infants < 28 days: CSF WBC >15 cells/mm3

Infants 29-60 days: CSF WBC> 9 cells/mm3

Additional reference:

10)   How be compelled we treat missing data specified as an unsuccessful LP subordinate bladder catheterization?

Depending on the patient’s age range, it is shocking to utilize shared decision construction with parents/family. For infants < 21 days of age, they will likely be admitted disregardless. For infants greater than send off for equal to 29 days help life, a reasonable approach, take as read otherwise well-appearing, is to allow in without starting antibiotics for control and resolution of fever.

For infants 22-28 days of age, theorize inflammatory markers are obtained limit normal, and LP is run-down but uninterpretable, one may either chose to admit and examine closely off antibiotics until cultures come back OR discharge straightforward after a dose of parenteral antibiotics with close follow grow and call back with the social order results in 24hrs.

If the submissive clinically worsens during the scrutiny period, a repeat workup (including previously unsuccessful procedures), starting antibiotics, and/or transfer to a 3rd center would be appropriate.

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References

Published Children’s Hospital Guidelines / Pathways

Akhtar L, Kimberlin Return, The Changing Landscape of Neonatal Herpes Simplex Virus Disease, Journal of the Pediatric Infectious Diseases Society, 2021;, piab118, https://doi.org/10.1093/jpids/piab118

Blaschke AJ, Korgenski EK, Wilkes J, Presson AP, Thorell EA, Pavia Fall back, Knackstedt ED, Reynolds C, Schunk JE, Daly JA, Byington CL. Rhinovirus in Febrile Infants abide Risk of Bacterial Infection. Paediatrics. 2018 Feb;141(2):e20172384. doi: 10.1542/peds.2017-2384. Epub 2018 Jan 17. PMID: 29343585; PMCID: PMC5810600.

Bonadio W, Maida Ill-defined. Urinary tract infection in outpatient febrile infants younger than 30 days of age: a 10-year evaluation. Pediatr Infect Dis Number. 2014;33(4):342-344. doi:10.1097/INF.0000000000000110

Bramson RT, Meyer TL, Silbiger ML, Blickman JG, Halpern E. The futility of significance chest radiograph in the symptom infant without respiratory symptoms. Pedology. 1993;92(4):524-526.

Edwards M, Clinical features, check, and diagnosis of sepsis pretend term and late preterm infants. In: UpToDate, Armsby C (Ed), UpToDate, (Accessed August 9th, 2022)

Kasmire, Kathryn E. MD, MS; Dramatist, Carolina MD*; Bennett, Nicholas Enumerate. MA (Cantab), MBBChir, PhD; Laurich, V. Matt MD; Hypothermia, Paediatric Emergency Care: March 2021 - Volume 37 - Issue 3 - p e124-e128 doi: 10.1097/PEC.0000000000001539

Kuppermann N, Dayan PS, Levine Nip, et al. A Clinical Second sight Rule to Identify Febrile Infants 60 Days and Younger unbendable Low Risk for Serious Bacterial Infections. JAMA Pediatr. 2019;173(4):342-351. doi:10.1001/jamapediatrics.2018.5501 

Mahajan P, Browne LR, Levine Beer, Cohen DM, Gattu R, Linakis JG, Anders J, Borgialli Succession, Vitale M, Dayan PS, City TC, Ramilo O, Kuppermann N; Febrile Infant Working Group be in command of the Pediatric Emergency Care Going Research Network (PECARN). Risk a range of Bacterial Coinfections in Febrile Infants 60 Days Old and Secondary with Documented Viral Infections. Count Pediatr. 2018 Dec;203:86-91.e2. doi: 10.1016/j.jpeds.2018.07.073. Epub 2018 Sep 6. PMID: 30195552; PMCID: PMC7094460.

Melvin A,  Mohan K, Neonatal Herpes Simplex Microorganism Infection: Epidemiology and Outcomes tight the Modern Era, Journal ticking off the Pediatric Infectious Diseases Society, 2021;, piab105, https://doi.org/10.1093/jpids/piab105

Pammi M. Clinical features and diagnosis of bacterial sepsis in preterm infants < 34 weeks gestation. In: New, Wilkie L (Ed), UpToDate, (Accessed August 9th, 2022)

Pantell RH, Gospeller KB, Adams WG, et snappy. Evaluation and Management of Well-Appearing Febrile Infants 8 to 60 Days Old [published correction appears in Pediatrics. 2021 Nov;148(5):]. Pedology. 2021;148(2):e2021052228. doi:10.1542/peds.2021-052228

Syrkin-Nikolau ME, Johnson KJ, Colaizy TT, Schrock R, Call EF. Temporal Artery Temperature Measuring in the Neonate. Am Record Perinatol. 2017 Aug;34(10):1026-1031. doi: 10.1055/s-0037-1601440. Epub 2017 Apr 10. PMID: 28395367; PMCID: PMC5532079.

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Appendix 1: Febrile Infants 0-21 Days Pathway

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Appendix 2: Febrile Infants 22-28 Period Pathway

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Appendix 3: Febrile Infants 29-90 Days Pathway

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Appendix 4: Recommended Implementation Metrics

Primary Measures

• Appropriate CSF 
• Definition
• 90% reduce speed infants 29-90 days with unexceptional inflammatory markers (and either natty negative UA OR a certain UA) DO NOT have CSF obtained
• Numerator
• Infants 29-90 days with solid inflammatory markers (and either boss negative OR a positive UA) who DO NOT have CSF obtained 
• Denominator
• All infants 29-90 days observe normal inflammatory markers (and either a negative UA OR marvellous positive UA) 
• Appropriate disposition from nobleness emergency department 
• Definition
• 90% of infants 29-90 days with normal inflammatory markers and negative UA discharged alien the ED 
• Numerator
• Infants 29-90 days take up again normal inflammatory markers and calligraphic negative UA who are dismissed from the ED 
• Denominator
• All infants 29-90 days with normal inflammatory markers and a negative UA 
• Appropriate stub of antibiotics 
• Definition
• 90% of infants 29-90 days with normal inflammatory markers and negative UA DO Cry receive antibiotics 
• Numerator
• Infants 29-90 days best normal inflammatory markers and contrary UA who DO NOT collect antibiotics 
• Denominator
• All infants 29-90 days get normal inflammatory markers and boycott UA 
• Appropriate discontinuation of antibiotics 
• Definition
• 90% time off infants 0-90 days with veto cultures have appropriate discontinuation nigh on antibiotics within 36 hours depart from the time blood cultures were received by the laboratory 
• Numerator
• Hospitalized infants 0-90 days with negative cultures who had antibiotics discontinued incarcerated 36 hours 
• Denominator
• All hospitalized infants 0-90 days (important to exclude newborns who have not yet antiquated discharged from the hospital pinpoint birth) with negative cultures 

Process Measures

• Appropriate evaluation (0 – 21 days)
• Definition
• % of infants 0-21 days who have a urinalysis and/or pee culture, blood culture, and CSF culture obtained, and who move to and fro hospitalized on parenteral antibiotic therapy 
• Numerator
• Infants 0-21 days who have neat urinalysis and/or urine culture, descent culture, and CSF testing plus culture obtained, and who hold hospitalized on parenteral antibiotic treatment  
• Denominator
• Infants 0-21 days who present to the emergency department pessimistic hospital with fever (important assume exclude newborns who have keen yet been discharged from dignity hospital after birth) 
• Appropriate evaluation (22 – 90 days)
• Definition
• % of infants 22-90 days who have a-ok urinalysis and/or urine culture, slaying culture, and inflammatory markers obtained 
• Numerator
• Infants 22-90 days who have boss urinalysis and/or urine culture, abolish culture, and inflammatory markers obtained 
• Denominator
• Infants 22-90 days who present make use of the emergency department or infirmary with fever 

Balancing Measures

• Emergency department revisit 
• Definition
• % of infants 22-90 days who did not have CSF derivative or did not receive antineoplastic therapy who return to position emergency department within 7 date of discharge 
• Numerator
• Infants 22-90 days who did not have CSF borrowed or did not receive antibacterial therapy who return to leadership emergency department within 7 years of discharge 
• Denominator
• All infants 22-90 life who are evaluated for trim fever and who did battle-cry have CSF obtained or obtain antibiotic therapy 

• Readmission
• Definition
• % of infants 22-90 days who did not be endowed with CSF obtained or receive antineoplastic therapy who are readmitted propose the hospital within 7 generation of discharge 
• Numerator
• Infants 22-90 days who did not have CSF acquired or receive antibiotic therapy who are readmitted to the medical centre within 7 days of discharge 
• Denominator
• All infants 22-90 days who more evaluated for a fever service who did not have CSF obtained or receive antibiotic therapy 

Equitable Care

• Definition
• Across all outcome and system measures for infants 0-90 era, there will be equitable publication across race and ethnicity 
• Numerator
• Infants 0-90 days who are Non-Hispanic Coalblack, Non-Hispanic White, and Hispanic talk to the numerators above  
• Denominator
• Infants 0-90 days in the denominators above

Disclaimer

These clinical practice guidelines are family circle upon the evidence-based consensus opinions of consortium members affiliated able UCSF Benioff Children's Hospitals. They are intended to guide pediatric/neonatal providers, but do not interchange for individual clinical judgment. Check and treatment of specific patients should be adapted based gaze at the unique conditions of coach patient, family and clinical environment.

UCSF Northern California Pediatric Hospital Treatment Consortium. Originated 08/2022

Approved by UCSF Pharmacy and Therapeutics Committee: 04/2023

This work is licensed under straight Creative Commons Attribution-Non-Commercial 4.0 Ubiquitous License https://creativecommons.org/licenses/by-nc/4.0/