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South Australian Paediatric Clinical Practice Guideline
Fever in Children
aged 1-2 months
Department of Health and Wellbeing, Government of South Australia. All rights reserved.
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Note:
This guideline provides advice of a general nature. This statewide guideline has been prepared to promote and facilitate
standardisation and consistency of practice, using a multidisciplinary approach. The guideline is based on a review of
published evidence and expert opinion.
Information in this statewide guideline is current at the time of publication.
SA Health does not accept responsibility for the quality or accuracy of material on websites linked from this site and does not
sponsor, approve or endorse materials on such links.
Health practitioners in the South Australian public health sector are expected to review specific details of each patient and
professionally assess the applicability of the relevant guideline to that clinical situation.
If for good clinical reasons, a decision is made to depart from the guideline, the responsible clinician must document in the
patient s medical record, the decision made, by whom, and detailed reasons for the departure from the guideline.
This statewide guideline does not address all the elements of clinical practice and assumes that the individual clinicians are
responsible for discussing care with consumers in an environment that is culturally appropriate and which enables respectful
confidential discussion. This includes:
The use of interpreter services where necessary,
Advising consumers of their choice and ensuring informed consent is obtained,
Providing care within scope of practice, meeting all legislative requirements and maintaining standards of
professional conduct, and
Documenting all care in accordance with mandatory and local requirements
Explanation of the aboriginal artwork:
The aboriginal artwork used symbolises the connection to country and the circle shape shows the strong relationships amongst families and the aboriginal culture. The horse shoe shape
design shown in front of the generic statement symbolises a woman and those enclosing a smaller horse shoe shape depicts a pregnant women. The smaller horse shoe shape in this
instance represents the unborn child. The artwork shown before the specific statements within the document symbolises a footprint and demonstrates the need to move forward together in
unison.
The term Aboriginal is used to refer to people who identify as Aboriginal, Torres Strait Islanders, or both Aboriginal and Torres Strait
Islander. This is done because the people indigenous to South Australia are Aboriginal and we respect that many Aboriginal people prefer the
term Aboriginal . We also acknowledge and respect that many Aboriginal South Australians prefer to be known by their specific language
group(s)
Cultural safety enhances clinical safety.
To secure the best health outcomes, clinicians must provide a culturally safe health
care experience for Aboriginal children, young people and their families. Aboriginal
children are born into strong kinship structures where roles and responsibilities are
integral and woven into the social fabric of Aboriginal societies.
Australian Aboriginal culture is the oldest living culture in the world, yet Aboriginal
people currently experience the poorest health outcomes when compared to non-
Aboriginal Australians.
It remains a national disgrace that Australia has one of the highest youth suicide rates
in the world. The over representation of Aboriginal children and young people in out
of home care and juvenile detention and justice system is intolerable.
The cumulated effects of forced removal of Aboriginal children, poverty, exposure to
violence, historical and transgenerational trauma, the ongoing effects of past and
present systemic racism, culturally unsafe and discriminatory health services are all
major contributors to the disparities in Aboriginal health outcomes.
Clinicians can secure positive long term health and wellbeing outcomes by making
well informed clinical decisions based on cultural considerations.
Fever in Children aged 1-2 months
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Purpose and Scope of PCPG
The Management of the Children with Fever aged 1-2 months Clinical Guideline is primarily
aimed at medical staff working in any of primary care, local, regional, general or tertiary
hospitals. It may also assist the care provided by other clinicians such as nurses. The
information is current at the time of publication and provides a minimum standard for the
assessment (including investigations) and management of children with fever aged 1-2
months; it does not replace or remove clinical judgement or the professional care and duty
necessary for each specific case.
Flowchart
Fever in Children aged 1-2 months
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Table of Contents
Purpose and Scope of PCPG .................................................................................................... 2
Important Points ......................................................................................................................... 4
Abbreviations ............................................................................................................................. 4
Definitions .................................................................................................................................. 5
Fever ...................................................................................................................................... 5
Serious Bacterial Infection (SBI) ............................................................................................ 5
Occult Bacteraemia................................................................................................................ 5
Fever without a focus ............................................................................................................. 5
Introduction ................................................................................................................................ 6
Assessment ............................................................................................................................... 6
South Australian Ambulance Service (SAAS) Assessment and Referral .............................. 6
Primary care / outpatient history and examination ................................................................ 7
Investigations and Management of fever without focus ............................................................ 8
Investigations ......................................................................................................................... 8
Infants aged <1 month ........................................................................................................... 8
Assessment and management .............................................................................................. 8
Admission Criteria .................................................................................................................. 8
Referral Criteria ...................................................................................................................... 8
Infants aged 1-2 months ............................................................................................................ 8
Toxic on assessment ............................................................................................................. 8
Referral Criteria ........................................................................................................................ 10
References ............................................................................................................................... 10
Acknowledgements .................................................................................................................. 11
Document Ownership & History ............................................................................................... 11
Appendices
APPENDIX 1 Urine Collection Methods ........................................................................... 12
APPENDIX 2 CSF Interpretation ...................................................................................... 13
APPENDIX 3 Contraindications to Lumbar Puncture ....................................................... 15
APPENDIX 4 Investigations .............................................................................................. 16
APPENDIX 5 Discharge Criteria ....................................................................................... 17
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Important Points
> The flow diagram included in this document has been locally adapted from the Children s
hospital at Westmead. The upper limit of normal for cut off values for both CRP and PCT
investigations have been lowered to better reflect local SA clinical practice. These changes
along with others however may invalidate the published findings from this protocol, in
particular reducing the specificity and sensitivity of identifying severe bacterial infection
(SBI).
> Children assessed as non-toxic but having any abnormal laboratory findings in this
document do not automatically proceed to a full septic work up. The South Australian
consensus recommendation is that they discuss the need for any additional investigations
with a senior doctor first. This would generally include a consultant paediatrician, fellow or
senior registrar. While this approach is likely to result in a reduction in the number of LP s
performed compared to the published recommendations, there is also the potential for
missing meningitis cases.
> All infants under 2 months of age with fever should have a bacterial source of infection
sought clinically from history, examination and appropriate directed investigations. There is
a difficult balance between missing SBI and unnecessarily invasive diagnostic testing and
risks of unnecessary antibiotic exposure in early life. There is no single test, combination of
tests or clinical findings that can reliably predict SBI with 100% accuracy in children. Hence
the variation in approaches from the literature.
> All infants under 30 days of age should be managed according to the NEONATAL SEPSIS
PATHWAY and any children requiring resuscitation should be also assessed and managed
immediately according to the PAEDIATRIC SEPSIS GUIDELINE before following the fever
without focus guideline.
Abbreviations
mg milligram(s)
L litre(s)
g microgram(s)
L microlitre(s)
kg kilogram(s)
cm centimetre
PCR polymerase chain reaction
HSV herpes simplex virus
VZV varicella-zoster virus
UTI urinary tract infection
IV intravenous
IM intramuscular
LP lumbar puncture
NPA nasopharyngeal aspiration
CNS central nervous system
RR respiratory rate
CBC complete blood count
CRP C-reactive protein
CSF cerebrospinal fluid
URTI upper respiratory tract infection
WBC white blood cell count
WCC white cell count
NICU neonatal intensive care unit
CFU colony-forming unit
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Definitions
Fever > For the purposes of this guideline fever is defined as axillary
temperature>=38 in hospital, or GP practice or home in the last 24 hours.
> For routine monitoring of stable patients, temperature may be measured
at the axilla, rectally, orally or via the ear (tympanic). Rectal temperatures
are considered the gold standard as they correlate better with core
temperature. Axillary temperatures have a lower correlation. Tympanic
temperature measurements are less reliable and should not be
preferentially used. If there is any doubt about a child s temperature, it
should be repeated, and measurement of rectal temperature should be
considered in infants 1-2 months age where other methods have been
unsuccessful (this is rarely required in practice and appropriate local
procedures should be followed as this is an invasive procedure).
> It should be noted that children, but particularly neonates, may respond to
serious bacterial infection with hypothermia, thus any child with low
temperature or other signs of toxicity should also be evaluated for
infection/ bacteraemia.
> A fever recorded by thermometer at home should be approached in the
same manner as a fever recorded in the hospital.
Serious
Bacterial
Infection
(SBI)
> Includes urinary tract infection, pneumonia, meningitis, bacteraemia or
septicaemia, bone and joint infection, skin and soft tissue infection and
bacterial enteritis.
> The risk of SBI increases with the height of fever in children less than 6
months compared to over 6 months of age.
> Note that SBI can be present with low-grade fever, in the absence of
fever or with hypothermia particularly in the very young.
> In febrile children, the rate of SBI increases with decreasing age (13-25%
age 0-4 weeks, 8% age 4-8 weeks, children aged 3-36 months ranges
from 2 to 12%)
Occult
Bacteraemia
> Defined as bacteraemia in a child who has no clinical focus of infection.
> Conjugated Pneumococcal vaccine has dramatically reduced the
incidence of occult Pneumococcal bacteraemia. There is, however, still
too little clear epidemiological data upon which changes to the
recommendations for empiric therapy of the febrile child can be based.
Fever
without a
focus
> Literature suggests that SBI continues to occur in the presence of
concomitant viral infections, with as many as 5% of patients with
confirmed viral sources having urinary tract infections or other SBIs.
Infants and children presenting with a fever and signs of a viral illness
(URTI, bronchiolitis, croup, skin or mucosal lesions) may have
investigations performed to confirm the viral aetiology (such as an NPA for
respiratory viruses and sterile site PCR on blood for HSV, VZV,
enterovirus, parechovirus) but should also be assessed for bacterial
infections as outlined below.
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Introduction
> Fever is one of the most common acute presentations in childhood.
> Many children will be only mildly unwell and will have a focus of infection identified on history
and examination. The majority of febrile illnesses in young children are caused by viruses, but
up to 5% of young children with a significant fever will have a bacterial cause
> The aim of this guideline is to detect those children at risk from serious bacterial infection
(SBI) presenting with fever without focus. This requires a combination of clinical judgement,
specific investigations and a period of observation. If the source of fever is found, then the
appropriate treatment guideline for that diagnosis should be followed.
> This guideline MUST NOT be used for :
1) Neonates, 30 days of age or less, refer to NEONATAL FEVER/SEPSIS GUIDELINE
available at: https://extapps2.sahealth.sa.gov.au/PracticeGuidelines/.
2) Children with any underlying disorders that affect their immunity or might otherwise
increase their risk for serious bacterial or viral infections e.g. cystic fibrosis, oncology
patients, known acquired or congenital immune deficiency, those on long term
immunosuppressive therapy. Refer to individual guidelines (e.g. FEBRILE
NEUTROPENIA IN PAEDIATRICS) or seek specialist guidance.
3) Any patient that meets criteria for sepsis or severe sepsis/septic shock please refer to
local sepsis guidelines and seek specialist paediatric advice.
4) Children aged >2 months of age.
If a child is already receiving antibiotics, any clinical signs may be more subtle and
clinicians require a higher index of suspicion for the possibility of partially treated
infections.
> The degree or height of fever, its speed of onset and its response to antipyretics are all poor
predictors of serious illness by themselves. Any febrile child who appears unwell or toxic
should be investigated and treated according to the PAEDIATRIC SEPSIS PATHWAY
irrespective of the degree or height of fever.
Assessment
South Australian Ambulance Service (SAAS) Assessment and Referral
> Primary and secondary survey should be completed, with a focus on assessing for the signs
of toxicity as outlined in the table 1 below.
o If shock is present it should be immediately managed with IV fluid resuscitation and
intravenous antibiotics as per the NEONATAL OR PAEDIATRIC SEPSIS PATHWAY
guideline available at: https://extapps2.sahealth.sa.gov.au/PracticeGuidelines/.
o In toxic infants with or without a petechial/purpuric rash, consideration should be given
to a single immediate dose of IV/IM benzylpenicillin.
This should be done in consultation with the on duty ambulance service medical officer /
clinical support.
> Prehospital measurement of temperature may not be possible or reliable, and a domestic
thermometer may read falsely low. If temperature can be formally assessed, it should be done
via the axilla. A fever measured at home by the parents should be accepted as a documented
fever. If temperature cannot be measured but the infant/child appears unwell or toxic to either
prehospital providers or the parents, the child should receive further formal medical
assessment.
> Non-toxic infants aged 1-2 months with a recorded or reported temperature ?38 degrees
should be formally and promptly assessed by a medical practitioner in a clinical setting where
investigations such as blood cultures, lumbar puncture and urinalysis can be safely
performed.
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> Antipyretics are not necessary in the pre-hospital setting if a fever is present - they are
primarily a comfort measure but do not prevent complications such as febrile convulsions.
Parents may decide to give antipyretics at their own discretion (If used, paracetamol is
preferred).
Primary care / outpatient history and examination
> Every child presenting with fever should have a thorough history taken and examination
focusing on symptoms and signs of specific infections as well as general assessment to their
degree of illness (table 1).
> The child s immunisation status must also be checked, especially regarding Pneumococcal,
Meningococcal and Haemophilus immunisations
> Younger infants usually present with non-specific symptoms and signs of illness, and
localising signs of disease are often lacking. General aspects of the child's behaviour and
appearance provide the best indication of whether a serious infection is likely.
> Because bacteraemia can occur with focal infections, it is recommended that when a source
of infection is identified on physical examination, further evaluation be considered if the doctor
judges that focal findings are insufficient to explain the degree of the child's fever and illness.
If the source of the fever is found, then appropriate management should be instituted.
Table 1 Extended assessment of Toxicity
Note: Any child assessed as being toxic must be seen by the most experienced Medical
Officer available as soon as possible.
Well Unwell Toxic
Alertness /
Activity
Strong cry or not
crying
Content, smiles
Stays awake
Normal response
to social cues
Drowsy / decreased
activity
Poor smile/response to
social cues
Irritable
Wakes only with prolonged
stimulation or unable to
rouse
Weak/high pitched or
continuous cry
Bulging fontanelle
Breathing Normal work of
breathing
Nasal flaring Chest in-drawing RR>60
Grunting
Colour /
Circulation
Normal lips, skin
and tongue colour
Pallor per caregiver Pale, mottled
Blue, ashen
Cool Peripheries
Bounding pulses or wide
pulse pressure
Fluid / Urine
output
Normal skin and
eyes
Moist mucous
membranes
Poor feeding in infant
Dry mucous
membranes
Reduced urine output
Reduced skin turgor
Bilious vomiting
Decreased fluid intake by
<1/2 normal
Decreased urine output
less than 4 wet nappies
over 24 hours
Other New lump >2cm Rigors, seizure
Petechial rash
Appears very unwell to
healthcare professional
Persistent tachycardia
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Investigations and Management of fever without focus
Investigations
> Children at higher risk of SBI should usually have appropriate investigations performed
according to their age and risk group, as per flow chart.
Infants aged <1 month
Assessment and management
> Refer to NEONATAL SEPSIS PATHWAY for assessment, investigation and management for
all infants less than 30 days of age available at:
https://extapps2.sahealth.sa.gov.au/PracticeGuidelines/.
Admission Criteria
> All neonates with fever and without a source of infection should be hospitalized. If this
necessitates transfer from a rural facility, the first dose of antibiotics should usually be given
prior to transfer.
Referral Criteria
> Infants with fever who show any signs of toxicity and/or showing signs of meningococcal
disease should be urgently reviewed by an experienced paediatrician and consideration given
to referral to paediatric intensive care after need for any fluid resuscitation and antibiotics
have been given.
> Retrieval to intensive care, if required, should be arranged by calling MedSTAR kids.
Infants aged 1-2 months
> Referral for immediate investigations at an appropriate facility should be strongly considered
in all infants aged 1-2 months of age presenting with fever and without focus.
Toxic on assessment
High risk category
> All Infant 1-2 months with any signs or symptoms in the toxic category should be assessed
for sepsis/shock and receive appropriate resuscitation measures first.
> Infants should receive a full septic screen as below including LP (providing no
contraindications) and commence empiric intravenous antibiotic therapy as soon as possible.
> The following investigations are recommended as minimum for a full septic screen:
o CBE with differential (+/- film)
o Blood culture
o Sterile site PCR panel from blood (HSV, VZV, enterovirus, parechovirus,
pneumococcal, meningococcal)
o CRP
o Pro-calcitonin (where testing is available)
o Urinalysis and urine microscopy, urine culture (SPA/catheter/clean catch specimen)
o Lumbar puncture (LP) should be performed in any child with signs or symptoms of
meningitis and/or those appearing toxic and without contra-indications.
o CSF request should include Microscopy/Gram staining/Culture/ PCR panel for CNS
pathogens and biochemistry where ever possible.
> Chest X-ray, especially if increased work of breathing OR any respiratory symptoms or low
oxygen saturation (<=93% in room air) OR fever >39 C and WBC>20,000 (as screen for
occult bacterial pneumonia).
> Combined nose/throat swab for respiratory viral screen if appropriate.
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Non-toxic on assessment
Low risk category
> A child is considered lower risk from serious infection providing they:
a) Do not have any of the following abnormal laboratory results including: WCC >15 000 or
<4000, or absolute neutrophil counts >10,000 or < 1,000, and /or raised CRP>20, and/or
PCT >0.5.
b) Were born at full term (>37 weeks gestation)
c) Have had no previous prolonged NICU stay
d) Have no chronic medical problems/diagnoses
e) Did not receive antibiotic within 3 days of presentation
f) Well appearing and easily consolable
g) No evidence of any infection clinically
Lower-risk infants without any toxic features on assessment and with normal investigations above
still require hospital admission for a period of regular observation. Some of these infants may
then be discharged providing they improve clinically and meet the discharge criteria.
Intermediate category
A non-toxic appearing child is considered may be considered at intermediate risk from serious
infection if they have 1 or more of the following abnormal laboratory results including WCC >15
000 or <4000, or absolute neutrophil counts >10,000 or < 1,000, and /or raised CRP>20, and/or
PCT >0.5.
These infants may require further investigations including full septic screen as above, before
considering any empiric antibiotic therapy.
It is recommended that these infants are always discussed with a senior doctor
(Paediatrician/Fellow or senior Registrar) before performing any additional investigations.
All children in this category will require admission to hospital for observation and treatment if
clinically indicated.
Recommended empiric antibiotic therapy
> Infants requiring a full sepsis screen should be commenced and continued on empiric therapy
below, until meningitis can be excluded or if the CSF status is unknown or unable to be
interpreted (i.e. bloody tap, child too sick for LP, previous antibiotic therapy) then commence
as per eTGA guidelines:
o Cefotaxime 50 mg/kg IV 6 hourly
PLUS
o Amoxicillin 50mg/kg/Dose IV 6 hourly
> Consider adding intravenous acyclovir (20mg/kg/dose 8 hourly) for empiric treatment
of HSV if this is clinically suspected or has if patient has had known contact with a
person with active HSV infection.
For infants at increased risk of MRSA infection (see below) add vancomycin to the
above regimens 30mg/kg/dose up to 1.5 g IV 12 hourly.
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Risk factors for infection with MRSA include:
> residence in an area with a high prevalence of MRSA (e.g. Northern Territory; remote
communities in northern Queensland; regions north of metropolitan Perth in Western
Australia, especially the Kimberly and Pilbara)
> previous colonisation or infection with MRSA, particularly if recent or associated with the
current episode of care.
> frequent stays, or a current prolonged stay, in a hospital with a high prevalence of MRSA,
particularly if associated with antibiotic exposure or recent surgery
> exposed to a care giver colonised or infected with MRSA.
If Meningitis can be excluded in infants aged 1-2 months:
> Where all CSF parameters are considered to be within the normal range (see APPENDIX 2)
and Gram stain is negative then it would be reasonable to give according to the eTGA
guidelines:
o Amoxicillin 50mg/kg/dose IV 6 hourly
PLUS
o Gentamicin* 7.5 mg/kg IV once daily.
Gentamicin levels should be monitored according to local guidelines.
*If gentamicin cannot be used then Amoxicillin plus Cefotaxime is recommended using the
doses as above.
For infants at increased risk of MRSA infection (see criteria above) add vancomycin to
the above regimens 30mg/kg/dose up to 1.5 g IV 12 hourly.
> The use of antipyretics should not be routine for all febrile infants, but it should be considered
in those who appear distressed or unwell.
Referral Criteria
> Infants with fever who are shocked, unarousable or showing signs of meningococcal disease
should be urgently reviewed by an experienced paediatrician and consideration given to
referral to paediatric intensive care after appropriate antibiotics have been given.
> Retrieval to intensive care, if required, should be arranged by calling MedSTAR kids on
(08) 8222 4222.
References
1. Hess A, Hanna D, Ging J, et al. Implementation of an evidence based guideline for the
management of fever in infants <3 months old. J Paed Child Health, 2017;53 (suppl 3):
20-21.
2. Aldridge P, Rao A, Sethumadavan R, et al. Fever under 3 months and the full septic
screen: Time to think again? A retrospective cohort study at a tertiary-level paediatric
hospital. J Paed Child Health, 2018;54:272-273.
3. Children s Hospital of Philadelphia. ED pathway for evaluation /Treatment of Febrile
young Infants (0-56 days Old). https://www.chop.edu/clinical-pathway/febrile-infant-
emergent-evaluation-clinical-pathway.
4. Febrile child. Royal Children s Hospital Melbourne
https://www.rch.org.au/clinicalguide/guideline_index/Febrile_child/
5. eTG complete Therapeutic Guidelines, viewed 3 October 2019,
https://tgldcdp.tg.org.au.
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Acknowledgements
The South Australian Child and Adolescent Health Community of Practice gratefully acknowledge
the contribution of clinicians and other stakeholders who participated throughout the guideline
development process particularly:
Write Group
Dr Brett Ritchie
Dr Simon Chu
Dr Brian Coppin
SA Paediatric Clinical Practice Guideline Reference Group Members
Document Ownership & History
Developed by: SA Child & Adolescent Health Community of Practice
Contact: Health.PaediatricClinicalGuidelines@sa.gov.au
Endorsed by: SA Safety and Quality Strategic Governance Committee
Next review due: 04/03/2025
ISBN number: 978-1-74243-899-3
PDS reference: CG093
Policy history: Is this a new policy (V1)? N
Does this policy amend or update and existing policy? Y
If so, which version? V3
Does this policy replace another policy with a different title? Y
If so, which policy (title)? Children with fever aged 1-2 months
Approval
Date Version
Who approved
New/Revised Version Reason for Change
07/09/20 V3.1 Chair, Child and Adolescent Health Community of Practice Name change
04/03/20 V3
Deputy Chief Executive,
Department for Health and
Welfare
Name change and formal review in
line with 1-5 year scheduled review
timeline.
01/07/13 V2 SA Safety and Quality Strategic Governance Committee
Formally reviewed in line with 2
year scheduled timeline for review
09/03/12 V1 SA Safety and Quality Strategic Governance Committee
Original SA Safety and Quality
Strategic Governance Committee
approved version.
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Appendices
APPENDIX 1 Urine Collection Methods
Screening methods
1. Bag Urine
Useful for collecting urine for urinalysis for screening purposes in infants and children who
cannot void on request (approx. 0-3 years - not recommended in neonates)
This method is only valid if negative and clinical suspicion is low. There is a high risk for
contamination and it is therefore unreliable if positive even when a pure growth of
organism is cultured.
A bag sample of urine should only be sent to the laboratory for urinalysis and culture if a
definitive sample cannot be obtained and treatment needs to be started urgently
(e.g. a septic neonate with dry tap on suprapubic aspiration [SPA]).
(Some centres use sterile cotton balls in a nappy (after cleaning the area) to collect a
sample equivalent to a bag specimen in non-toxic looking babies. There is some evidence
for this.)
2. Clean Catch
Requires careful cleansing of skin and good technique
These specimens can be readily contaminated by skin commensals.
A pure growth of > 105 cfu/ml in association with pyuria may indicate infection, but is less
reliable than a definitive sample though better than a bag sample.
Definitive methods
1. Midstream specimen of urine (MSU)
This can be obtained from children who can void on request. Clean catch specimens,
particularly in females, are frequently contaminated.
A pure growth of > 105 cfu/ml (for coliforms) or >104 for Gram positive pathogens in
association with pyuria indicates infection.
2. In-Out Catheter Specimens
Useful from about 6 months of age but can be performed as young as neonates.
These samples, once obtained, should always be sent for culture irrespective of
microscopy screening results. Any growth >105 cfu/ml (for coliforms) in association with
pyuria indicates infection. Note: the first part of the specimen can be contaminated and
should ideally be discarded. Consider aspirating the catheter with 2 syringes and taking the
1st 3 ml in the first syringe which should be discarded if sufficient urine is collected with the
2nd syringe.
3. Supra-pubic aspiration (SPA)
Mostly used for infants less than 12 months but can be used up to 2 years of age.
These samples, once obtained, should always be sent for culture irrespective of
microscopy results. Any pure growth from SPA urine usually indicates infection but
contamination by skin commensals or faecal flora may produce a mixed growth.
Before attempting SPA, ultrasound guidance or a bladder scanner should be considered to
demonstrate presence of urine in the bladder where this is available.
Urine microscopy>10 WCC/ uL with or without organisms should raise suspicion of
possible UTI. Urine dipstick analysis provides clinicians with rapid result and should be
performed on all urine collected for suspected UTI.
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APPENDIX 2 CSF Interpretation
Normal values
> The presence of any neutrophils in the CSF is unusual in normal children and should raise
concern about bacterial meningitis
> Meningitis can occur in children with normal CSF microscopy. If it is clinically indicated,
children who have a normal CSF should still be treated with IV antibiotics +/- IV antiviral if
indicated pending STERILE SITE PCR panel and routine culture result.
Interpretation of CSF results
> Gram stain may be negative in up to 60% of cases of bacterial meningitis even without prior
antibiotics.
> Neither a normal Gram stain, nor a lymphocytosis excludes bacterial meningitis.
> Neutrophils may predominate in viral meningitis even after the first 24 hours.
> CSF findings in bacterial meningitis may mimic those found in viral meningitis (particularly
early on). It may be possible with modest accuracy to judge whether bacterial or viral is more
likely based on CSF parameters. However if the CSF is abnormal the safest course is to treat
as if it is bacterial meningitis
Other factors affecting results
White cell count Biochemistry
Neutrophils
(x 106/L)
Lymphocytes
(x 106/L)
Protein
(g/L)
Glucose
(CSF: blood ratio)
Normal
(>1 month of age) 0 <5 <1.0
>0.6
(or >2.5mmol.L)
White cell count Biochemistry
Neutrophils
(x 106/L)
Lymphocytes
(x 106/L)
Protein
(g/L)
Glucose
(CSF: blood ratio)
Bacterial
Meningitis
100-10,000
but may be
normal
Usually <100 >1.0
but may be
normal
<0.4
but may be
normal
Viral
Meningitis
Usually <100 10-1000
but may be
normal
0.4-1.0
but may be
normal
Usually normal
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1. Antibiotics prior to lumbar puncture
Prior antibiotics usually prevent the culture of bacteria from the CSF. Antibiotics are
unlikely to significantly affect the CSF cell count or biochemistry in samples taken <24
hours after antibiotics.
2. Seizures
Recent studies do not support the earlier belief that seizures can increase cell counts in
the absence of meningitis. It is safest to assume that seizures do not cause an increased
CSF cell count.
3. Traumatic tap
Some guidelines suggest that in traumatic taps 1 white blood cell can be allowed for every
500 to 700 red blood cells and 0.01g/L protein for every 1000 red cells.
However, rules based on a predicted white cell count in the CSF are not reliable.
In order not to miss any patients with meningitis, guidelines relating to decisions about who
not to treat for possible meningitis need to be conservative. The safest interpretation of a
traumatic tap is to count the total number of white cells, and disregard the red cell count. If
there are more white cells than the normal range for age, then the safest option is to treat.
Sterile site PCR
Blood and CSF PCR are routinely available for Neisseria meningitidis, Pneumococcus,
Enterovirus, Herpes Simplex, VZV and parechovirus.
As results are not immediately available, they will only help with decisions concerning need
for ongoing antibiotic and antiviral therapy.
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APPENDIX 3 Contraindications to Lumbar Puncture
> Coma: absent or non-purposeful response to painful stimulus.
> Signs of raised intracranial pressure: e.g. drowsy, diplopia, abnormal pupillary responses,
unilateral or bilateral motor posturing or papilloedema (NB. papilloedema is an unreliable and
late sign of raised ICP in meningitis; a bulging fontanelle in the absence of other signs of
raised ICP is not a contraindication).
> Cardiovascular compromise/ shock
> Respiratory compromise
> Focal neurological signs or seizures
> Recent seizures (within 30 minutes or not regained normal conscious level afterwards).
> Coagulopathy/thrombocytopenia
> Local infection (in the area where an LP would be performed)
> The febrile child with purpura where meningococcal infection is suspected with risk of
disseminated intravascular coagulation.
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APPENDIX 4 Investigations
1. CXR should be performed in all infants with fever and no focus under 3 months of age.
Indications for those over 3 month s age include: increased respiratory effort, tachypnoea,
SaO2<93% in room air and WCC>20,000.
2. Investigation criteria suggestive of infection in presence of fever:
WCC <5,000 OR >15000
Absolute neutrophil count <1,000 OR >10,000
CRP>20
CSF>5 WBC
Urine microscopy with >10 WBC/uL or bacterial seen
CXR signs of consolidation, collapse
3. Lumbar puncture
Should be performed (providing no contra-indications) in all infants under 3 months of age
with fever and without focus. For older febrile children without focus, indications include:
any unwell appearing child (especially under 12 months age where it is difficult to clinically
evaluate signs of meningitis), full or bulging fontanelle, vomiting, lethargy and drowsiness,
seizures.
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APPENDIX 5 Discharge Criteria
Criteria for discharging and infant or child with fever without focus should usually include:
> Age greater than 3 months
> No toxic appearance features
> No indications for ongoing intravenous therapy
> No higher risk laboratory investigation criteria
> Able to maintain adequate oral intake to maintain hydration
> Consideration of social circumstances of child, family, transport, etc.
> Education with parent information sheet, agreement with and compliance of management by
parent/care provider
> Review by medical practitioner within 24 hours
Purpose and Scope of PCPG
Important Points
Definitions
Fever
Serious Bacterial Infection (SBI)
Occult Bacteraemia
Fever without a focus
Introduction
Assessment
South Australian Ambulance Service (SAAS) Assessment and Referral
Primary care / outpatient history and examination
Investigations and Management of fever without focus
Investigations
Infants aged <1 month
Assessment and management
Admission Criteria
Referral Criteria
Infants aged 1-2 months
Toxic on assessment
Referral Criteria
References
Acknowledgements
Document Ownership & History
Appendices
APPENDIX 1 Urine Collection Methods
APPENDIX 2 CSF Interpretation
APPENDIX 3 Contraindications to Lumbar Puncture
APPENDIX 4 Investigations
APPENDIX 5 Discharge Criteria
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