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Bottom Line Recommendations: Summary of Pediatric Emergency Care Information for Healthcare Providers

Fever in Infants ≤ 60 days

Développé parBrett Burstein

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Dernière mise à jour
sept. 2025

Sujet

Summary

Febrile infants ≤60 days have a 2-3% risk of invasive bacterial infections (IBIs; bacteremia and meningitis).1 Most will have viral illnesses, but clinical exams alone cannot determine infection severity. Clinicians must balance the risks of a potentially serious infection with the harms of over-investigation.

This document reflects the recommendations in the Canadian Pediatric Society Position Statement on the management of well-appearing febrile young infants.2

What is Fever?

  • The gold standard for fever is a rectal temperature of ≥ 38.0°C. While less accurate, tactile and elevated temperatures measured at other body sites likely also correlate with true fever.3,4
  • Any suspicion of fever in infants ≤ 60 days requires evaluation; even one episode ≥ 38.0°C is significant.5,6 Consider repeat rectal measurements over a few hours if the temperature is near 38.0°C.
  • Fever should not be attributed to over-bundling unless serious illness is ruled out, as it rarely causes temperatures ≥ 38.0°C.7

General Management Principles

If a temperature is ≥ 38.0°C at home or in hospital, proceed with urgent evaluation:

  • Complete history and physical exam with vital signs, including repeat rectal temperature measurement.
  • Assess ABCs and intervene as necessary.
  • Discuss the risk of infection, recommended workup and management of febrile young infants with caregivers.

Management depends on the infant’s clinical status

  • Severely ill infant (e.g., unstable vital signs, poor perfusion): refer to TREKK’s Sepsis (if > 28 days old) or Critically Ill Neonate (if 0-28 days old) algorithms.
    • DO NOT DELAY antimicrobials if the infant is too unstable, or there are insufficient resources or provider experience to obtain all cultures.
    • Contact Pediatric Referral Centre to prepare for transport.
  • Ill-appearing but otherwise stable infant: perform full septic workup and promptly initiate antimicrobials.
    • Full septic workup: blood culture, CBC with differential, procalcitonin (PCT; if available), electrolytes, glucose, liver enzymes, urinalysis and microscopy, urine culture (catheter sample) and, if clinically stable, a lumbar puncture (LP) for CSF testing including cell count, Gram stain and culture.
  • Well-appearing infant: perform partial septic workup and risk stratification.
    • Partial septic workup: blood culture, CBC with differential, PCT (if available), electrolytes, glucose, urinalysis and microscopy, urine culture (catheter sample).
    • Assess risk of invasive bacterial infection (IBI) using one of the validated risk-stratification strategies outlined in Table 1 below. Refer to TREKK’s Fever in Infants ≤60 days Algorithm for further guidance regarding need for LP, empiric antimicrobials or admission to hospital.

Table 1: Risk-stratification Strategies

PECARN Rounded Rule 8
(PCT available; preferred method)

Aronson Rule 9
(PCT unavailable)

Infant is low-risk if:

  • Urinalysis negative (no leukocyte esterase (LE), no nitrites and ≤5 WBCs/hpf) AND
  • Absolute neutrophil count ≤4000/μL AND
  • PCT ≤0.5 ng/mL

Infant is low-risk if ≤1 point total:

  • Age < 21 days (1 point)
  • Highest rectal temperature measured in ED:
    • Afebrile in ED (0 points)
    • 38.0°C-38.4°C (2 points); or
    • ≥38.5°C (4 points)
  • Absolute neutrophil count ≥ 5185/μL (2 points)
  • Urinalysis positive (any LE, nitrites or >5 WBC/hpf) (3 points)

If infant does not meet low-risk criteria of either rule, they are considered HIGH-RISK.

  • In low-risk infants, the risk of IBI is very low. The number needed to test by LP to exclude one case of meningitis ranges between 333 to 2000 (Aronson)9 or 500 to undefinably high (PECARN).8

Caution: For risk-stratification without PCT (Aronson), or infants with fever <2 hours,10 maintain a lower threshold for LP and hospitalization, even if stratified as low-risk.

Additional considerations

  • Infants with a focal infection (e.g., skin, soft tissue or osteoarticular infection) may require further investigation and tailored treatment. Discuss with Pediatric Referral Centre.
  • Consider additional workup depending on symptoms: chest x-ray (respiratory signs/symptoms despite suctioning), viral panel testing (nasal congestion) and/or stool cultures/virology (diarrhea).
  • Treat infants with elevated CSF WBCs (>15 cells/mm3 for infants ≤28 days or >9 cells/mm3 for infants 29 – 60 days) empirically for possible bacterial meningitis AND herpes simplex virus (HSV) infection. 11
  • Admit and observe infants until bacterial cultures are negative at 36 hours if high-risk OR 24 hours if low-risk. 12, 13

Age-specific management

  • When more than one recommended option exists for a low-risk infant, providers should engage in shared decision-making, reflecting both provider and caregiver goals of care and risk tolerance. 14, 15
  • See Treatment section below for choice and dosing of empiric antimicrobials.

0-28 DAYS OF AGE IF STABLE AND WELL-APPEARING

  • Low-risk infants are admitted; there are 2 options for management:
    1. Option 1 – Admit for observation without LP or empiric antimicrobials.
    2. Option 2 – Perform LP and admit infants with a normal CSF WBC count, with or without empiric antimicrobials.
  • Any positive blood or urine culture should prompt LP for CSF testing (if not already performed) and initiation of empiric antimicrobials.
  • High-risk infants should have LP for CSF testing, empiric antimicrobials and be admitted for close observation pending culture results.

29-60 DAYS OF AGE IF STABLE AND WELL-APPEARING

  • Low-risk infants may be discharged; there are 2 options for management:
    1. Option 1 – Discharge home and arrange follow-up within 24-48 hours. Provide caregivers with anticipatory guidance on when to return to the Emergency Department (ED). Ensure appropriate follow-up of culture results.
    2. Option 2 – Admit for observation with no LP or empiric antimicrobials until all cultures are negative for 24 hours.
  • Infants 29-60 days old with a suspected ISOLATED UTI (e.g., urine positive for leukocyte esterase, nitrites or >5 WBC/hpf AND otherwise meeting the remainder of low-risk criteria; see Table 1) DO NOT require LP. Treat empirically with PO or IV antibiotics (10-14 days). Use shared decision-making to decide on admission versus discharge home.
  • Any positive blood culture should prompt LP for CSF testing (if not already performed) and initiation of empiric antimicrobials.
  • High-risk infants should have LP for CSF testing, empiric antimicrobials, and be admitted for close observation pending culture results.

Herpes Simples Virus (HSV)

  • HSV infection may have few signs but is associated with significant morbidity and mortality. Up to 50% of infants with HSV infections are afebrile.16,17 Some infants may have hypothermia.
  • Assess risk factors for HSV including maternal history of primary HSV infection, seizures/focal neurologic abnormalities, diffuse pneumonitis, skin vesicles, mucous membrane lesions, elevated CSF WBCs, coagulopathy, transaminitis, postnatal exposure to HSV. Consider using a HSV risk score.18
  • If there is concern for HSV infection, collect viral samples from any vesicular skin lesions, all mucous membranes, CSF and blood (if available). Start empiric treatment with IV acyclovir and contact Pediatric Referral Centre.

Infants Requiring Special Consideration

  • Infants with lab-confirmed viral illnesses still have a risk of IBI >1%.19,20 Infants with respiratory symptoms, including bronchiolitis, should follow the age-based recommendations above. Consider early discharge at 24 hours for high-risk infants that have a laboratory-confirmed virus other than rhinovirus.21
  • Further evaluation and Pediatric Referral Centre consultation is recommended for infants with:
    • Known comorbidities (e.g., congenital disorder, chromosomal abnormality, immunodeficiency, technology dependence)
    • Treatment with antimicrobials within the preceding 7 days
    • Prolonged newborn nursery/NICU course or recent hospitalization o Prematurity (< 37 weeks gestation)
    • Seizures

Treatment

Age

Empiric Antimicrobials*

0-7 days

Ampicillin 225 mg/kg/day IV divided q8h AND Gentamicin or Tobramycin 4 mg/kg/dose IV q24h

  • If suspected meningitis, add Cefotaxime 150 mg/kg/day IV divided q8h and discontinue Gentamycin/Tobramycin
  • If suspected HSV, add Acyclovir 60 mg/kg/day IV divided q8h

8-28 days

Ampicillin 300 mg/kg/day IV divided q6h AND Gentamicin or Tobramycin 5 mg/kg/dose IV q24h

  • If suspected meningitis, add Cefotaxime 200 mg/kg/day IV divided q6h and discontinue Gentamycin/Tobramycin
  • If suspected HSV, add Acyclovir 60 mg/kg/day IV divided q8h

29-60 days

Ceftriaxone 100 mg/kg/dose IV q24h

  • If suspected meningitis, Ceftriaxone 100 mg/kg/dose IV x 1 dose, and then 12 hours later continued Ceftriaxone 50 mg/kg/dose IV q12h
  • If suspected meningitis, add Vancomycin 60 mg/kg/day IV divided q6h
  • If suspected HSV, add Acyclovir 60 mg/kg/day IV divided q8h

29-60 days

If stable, well-appearing and suspected isolated UTI (positive urinalysis AND otherwise meeting remainder of low risk criteria), may treat with:

  • Cefixime 8 mg/kg/dose PO q24h x 10-14 days

*Reassess once cultures and sensitivities available.

Note: Ampicillin, gentamicin, tobramycin, cefotaxime and ceftriaxone may be given at doses above via the IO or IM routes if unable to establish an IV. Acyclovir and vancomycin may be given at doses above via the IO route if unable to establish an IV.

Maximum IM volume: 0 to 28 days old: 0.5 mL; 29 to 60 days old: 1 mL

IM site: anterolateral thigh (vastus lateralis)

Citation

Suggested citation: Burstein, B & Translating Emergency Knowledge for Kids (TREKK). (2025). Bottom Line Recommendations and Algorithm: Fever in Infants ≤ 60 days. Retrieved from https://trekk.ca/topic/fever.

Development Team

Thank you to the following content expert who led the development of the Fever in Infants ≤ 60 days Bottom Line Recommendations and Algorithm:

Brett Burstein, MDCM, PhD, MPH, FRCPC, FAAP

Associate Professor, Department of Pediatrics, Faculty of Medicine and Health Sciences, McGill University, Pediatric Emergency Medicine Physician, Montreal Children’s Hospital

Thank you to the TREKK Editorial Committee, Editor Dr. Sarah Reid (CHEO), and CHRIM Parent and Youth Advisory Committee who provided editorial support and expertise in the development of this resource. Thank you as well to Mateja Carevic, TREKK Project Coordinator (University of Manitoba) who coordinated the development process.

Key References

(as cited in the Fever in Infants Bottom Line Recommendations):

  1. McCulloh RJ, McDaniel LM, Kerns E, Biondi EA. Prevalence of Invasive Bacterial Infections in Well-Appearing, Febrile Infants. Hosp Pediatr. Sep 2021;11(9):e184-e188. doi:10.1542/hpeds.2020-002147.
  2. Burstein B, Lirette MP, Beck C, Chauvin-Kimoff L, Chan K. Management of well-appearing febrile young infants aged ≤90 days. Paediatr Child Health. 2024 Feb 6;29(1):50-66. doi: 10.1093/pch/pxad085. PMID: 38332970; PMCID: PMC10848123.
  3. Bonadio WA, Hegenbarth M, Zachariason M. Correlating reported fever in young infants with subsequent temperature patterns and rate of serious bacterial infections. Pediatr Infect Dis J. 1990 Mar;9(3):158-60. doi: 10.1097/00006454-199003000-00002. PMID: 2336295.
  4. Caring For Kids. Fever and temperature taking. Accessed January 15, 2022, https://caringforkids.cps.ca/handouts/health-conditions-and-treatments/fever_and_temperature_taking
  5. Mintegi S, Gomez B, Carro A, Diaz H, Benito J. Invasive bacterial infections in young afebrile infants with a history of fever. Arch Dis Child. 2018 Jul;103(7):665-669. doi: 10.1136/archdischild-2017-313578. Epub 2018 Feb 15. PMID: 29449214.

  6. Ramgopal S, Janofsky S, Zuckerbraun NS, Ramilo O, Mahajan P, Kuppermann N, Vitale MA. Risk of Serious Bacterial Infection in Infants Aged ≤60 Days Presenting to Emergency Departments with a History of Fever Only. J Pediatr. 2019 Jan;204:191-195. doi: 10.1016/j.jpeds.2018.08.043. Epub 2018 Oct 2. PMID: 30291019.

  7. Grover G, Berkowitz CD, Lewis RJ, Thompson M, Berry L, Seidel J. The effects of bundling on infant temperature. Pediatrics. 1994 Nov;94(5):669-73. PMID: 7936893.
  8. Kuppermann N, Dayan PS, Levine DA, et al. A Clinical Prediction Rule to Identify Febrile Infants 60 Days and Younger at Low Risk for Serious Bacterial Infections. JAMA Pediatr. Apr 1 2019;173(4):342-351. doi:10.1001/jamapediatrics.2018.5501
  9. Aronson PL, Shabanova V, Shapiro ED, et al. A Prediction Model to Identify Febrile Infants </=60 Days at Low Risk of Invasive Bacterial Infection. Pediatrics. Jul 2019;144(1)doi:10.1542/peds.2018-3604
  10. Velasco R, Gomez B, Labiano I, Mier A, Ugedo A, Benito J, Mintegi S. Performance of Febrile Infant Algorithms by Duration of Fever. Pediatrics. 2024 May 1;153(5):e2023064342. doi: 10.1542/peds.2023-064342. PMID: 38563061
  11. Thomson J, Sucharew H, Cruz AT, et al. Cerebrospinal Fluid Reference Values for Young Infants Undergoing Lumbar Puncture. Pediatrics. Mar 2018;141(3)doi:10.1542/peds.2017-3405
  12. Aronson PL, Wang ME, Nigrovic LE, et al. Time to Pathogen Detection for Non-ill Versus Ill-Appearing Infants </=60 Days Old With Bacteremia and Meningitis. Hosp Pediatr. Jul 2018;8(7):379-384. doi:10.1542/hpeds.2018-0002
  13. Alpern ER, Kuppermann N, Blumberg S, Roosevelt G, Cruz AT, Nigrovic LE, Browne LR, VanBuren JM, Ramilo O, Mahajan P; PEDIATRIC EMERGENCY CARE APPLIED RESEARCH NETWORK (PECARN). Timeto Positive Blood and Cerebrospinal Fluid Cultures in Febrile Infants ≤60 Days of Age. Hosp Pediatr. 2020 Sep;10(9):719-727. doi: 10.1542/hpeds.2020-0045. PMID: 32868377; PMCID: PMC7446544.
  14. Coughlin KW. Medical decision-making in pediatrics: Infancy to adolescence. Paediatr Child Health. May 2018;23(2):138-146. doi:10.1093/pch/pxx127
  15. Sylvestre P, Aronson PL, Yannopoulos A, Poirier C, Gaucher N, Burstein B. Parental Preferences and Shared Decision-Making for the Management of Febrile Young Infants. Pediatrics. Sep 17 2024;154(4)doi:10.1542/peds.2024-066420

  16. Curfman AL, Glissmeyer EW, Ahmad FA, et al. Initial Presentation of Neonatal Herpes Simplex Virus Infection. J Pediatr. May 2016;172:121-126 e1. doi:10.1016/j.jpeds.2016.02.015

  17. James SH, Kimberlin DW. Neonatal Herpes Simplex Virus Infection. Infect Dis Clin North Am. Sep 2015;29(3):391-400. doi:10.1016/j.idc.2015.05.001
  18. Cruz AT, Nigrovic LE, Xie J, et al. Predictors of Invasive Herpes Simplex Virus Infection in Young Infants. Pediatrics. Sep 2021;148(3)doi:10.1542/peds.2021-050052
  19. Mahajan P, Browne LR, Levine DA, et al. Risk of Bacterial Coinfections in Febrile Infants 60 Days Old and Younger with Documented Viral Infections. J Pediatr. Dec 2018;203:86-91 e2. doi:10.1016/j.jpeds.2018.07.07
  20. Burstein B, Yannopoulos A, Dionne KA. Urinary Tract Infection, Bacteremia, and Meningitis Among Febrile Young Infants With SARS-CoV-2 and Non-SARS-CoV-2 Viral Infections. JAMA Netw Open. Jun 1 2023;6(6):e2321459. doi:10.1001/jamanetworkopen.2023.21459
  21. Blaschke AJ, Korgenski EK, Wilkes J, et al. Rhinovirus in Febrile Infants and Risk of Bacterial Infection. Pediatrics. Feb 2018;141(2)doi:10.1542/peds.2017-2384

For a complete list of the evidence that informed the creation of the Fever in Infants Bottom Line Recommendations and Algorithm see the Evidence Repository here.

To see our resource development process please visit our website here.

Evidence Repository

For a complete list of the evidence that informed the creation of the Fever in Infants Bottom Line Recommendations and Algorithm see the Evidence Repository here.

Disclaimer

The purpose of this document is to provide healthcare professionals with key facts and recommendations for the diagnosis and treatment of fever in infants ≤ 60 days in the emergency department. The TREKK Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. THIS DOCUMENT IS SUBJECT TO FULL DISCLAIMER HERE: trekk.ca/terms-of-use