Who the pathway covers
The pathway is for well-appearing term infants 8 to 60 days old with a documented temperature of 38.0 °C or higher, at home in the past 24 hours or in a clinical setting. Ill-appearing infants, infants 7 days or younger and infants over 60 days are outside it.
- Born before 37 weeks
- Under 2 weeks with perinatal maternal fever, infection or antibiotics
- Focal bacterial infection such as cellulitis, omphalitis, septic arthritis or osteomyelitis
- Clinical bronchiolitis, with or without a positive RSV test
- Documented or suspected immune compromise
- Neonatal course complicated by surgery or infection
- Congenital or chromosomal abnormality, or technology dependence
- Immunized within the last 48 hours
Inflammatory marker cut-offs
Markers are abnormal if procalcitonin is above 0.5 ng/mL, CRP is above 20 mg/L, or ANC is above 4,000/mm³. Without procalcitonin, markers are abnormal if CRP is above 20 mg/L, ANC is above 5,200/mm³, or temperature is above 38.5 °C. A positive urinalysis means leukocyte esterase, nitrite or pyuria.
Decisions by age group
The table summarizes the main branches for a well-appearing infant with no exclusions and no HSV concern.
| Age | Lumbar puncture | Antibiotics | Disposition |
|---|---|---|---|
| 8-21 days | Always | Parenteral, for all | Admit |
| 22-28 days, abnormal markers | Should be done | Parenteral ceftriaxone | Admit |
| 22-28 days, normal markers, positive urinalysis | Optional | Parenteral ceftriaxone | Admit |
| 22-28 days, normal markers and urinalysis, normal CSF | Optional (done) | Give first if going home; optional in hospital | Shared decision: home or hospital |
| 22-28 days, normal markers and urinalysis, no LP | Not done | Optional | Hospitalize |
| 29-60 days, abnormal markers | May be done | Parenteral ceftriaxone | Hospital, or home after a normal CSF |
| 29-60 days, normal markers, positive urinalysis | Not needed | Oral cephalexin or cefixime | Home if follow-up is assured |
| 29-60 days, normal markers, negative urinalysis | Not needed | None | Home, reevaluate in 24 h |
Workup at each age
At 8 to 21 days, send a urinalysis and urine culture by catheter or suprapubic aspirate, a blood culture and an LP (cell count, protein, glucose, Gram stain, culture). Inflammatory markers may also be sent. At 22 to 28 days, urine is collected the same way, with a blood culture and markers. At 29 to 60 days, a bag or voided urinalysis is fine, with culture by catheter or suprapubic aspirate if it is positive.
Pending or uninterpretable CSF is not a normal result. In that case the tool advises hospital observation with parenteral antibiotics and a repeat LP if meningitis is still possible.
Antibiotic doses
The tool lists these regimens from the guideline's Table 3.
- 8-21 days: ampicillin 150 mg/kg/day divided every 8 h, plus either ceftazidime 150 mg/kg/day divided every 8 h or gentamicin 4 mg/kg every 24 h
- 22-60 days: ceftriaxone 50 mg/kg every 24 h
- Meningitis, 8-28 days: ampicillin 300 mg/kg/day divided every 6 h plus ceftazidime 150 mg/kg/day divided every 8 h
- Meningitis, 29-60 days: ceftriaxone 100 mg/kg/day once daily (or 50 mg/kg every 12 h) plus vancomycin 60 mg/kg/day divided every 8 h
- Oral, positive urinalysis at 29-60 days: cephalexin 50-100 mg/kg/day in 4 doses, or cefixime 8 mg/kg/day in 1 dose
HSV concern and stopping antibiotics
Features that raise concern for HSV include maternal genital HSV lesions, maternal fever from 48 hours before to 48 hours after delivery, vesicles, seizures, hypothermia, mucous membrane ulcers, CSF pleocytosis with a negative Gram stain, leukopenia or thrombocytopenia, and an elevated ALT. These infants need CSF and blood HSV PCR, ALT and surface swabs, acyclovir 20 mg/kg every 8 hours with antibacterial cover, and admission.
Antibiotics can be stopped and the infant discharged when cultures are negative at 24 to 36 hours, the infant is well and there is no other reason to stay. Any home plan needs caregiver teaching, a reliable phone and transport, family agreement and reevaluation within 24 hours.
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Workup, antibiotics and disposition for well-appearing febrile infants 8–60 days.
Open Febrile Infant →Common questions
Does every febrile infant need a lumbar puncture?
No. Every infant 8 to 21 days gets one. At 22 to 28 days it should be done if markers are abnormal and is optional if they are normal. At 29 to 60 days with normal markers it is not needed.
What procalcitonin level is abnormal?
In the AAP 2021 pathway, procalcitonin above 0.5 ng/mL is abnormal, along with CRP above 20 mg/L or ANC above 4,000/mm³.
Can a febrile infant 29 to 60 days old go home?
Yes, if well-appearing with normal markers and a negative urinalysis: home without antibiotics, with reevaluation in 24 hours, caregiver teaching, reliable phone and transport, and family agreement.
What if the infant has bronchiolitis?
Bronchiolitis is an exclusion. Bacteremia and meningitis are rare, but UTI still occurs in about 1 to 3%, so the urine is still checked.
Sources
Pantell RH, Roberts KB, Adams WG, et al. Evaluation and management of well-appearing febrile infants 8 to 60 days old. American Academy of Pediatrics clinical practice guideline. Pediatrics 2021;148(2):e2021052228 (algorithms from Figures 1-3, antibiotic doses from Table 3, CSF reference ranges from Table 2).; Acyclovir and vancomycin doses from the AAP Red Book (2024-2027) neonatal dosing tables.; AAP bronchiolitis guideline 2014.
For education only, not medical advice. Always confirm against current guidelines and your local protocols. Pedemy is independent and not affiliated with or endorsed by the organizations cited.