Ill Appearing

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Order WBC, ANC, CRP, PCT, blood culture, urinalysis, urine culture (Class II)

Routine symptomatic treatment of low-grade fever is not necessary but can improve comfort. Parents should be advised that they do not need to wake a child from sleep to administer antipyretics. Acetaminophen 10 to 15 mg/kg orally every 4 to 6 hours or ibuprofen 5 to 10 mg/kg orally every 6 to 8 hours can be used as needed, though ibuprofen is often avoided in infants aged <6 months due to insufficient safety data associated with renal dysfunction. Avoid acetylsalicylic acid (aspirin) to treat fever, as it can lead to Reye syndrome (particularly with influenza infections, but there is an association with other viral, and even bacterial, infections).$^{122}$

Previously healthy, well-appearing children with no clear source of infection do not require antibiotics. If such a child was tested and testing is negative, no antibiotics are necessary.$^{84}$ Most viral syndromes (except in certain patients with influenza, varicella, or herpes) are also treated supportively, given the previously described low rate of comorbid SBI.$^{63,120}$

Patients with identified bacterial infections should be treated according to the source and local antibiograms.$^{123}$ There are no clear guidelines on whether previously healthy, well-appearing children with abnormal inflammatory markers and no source of infection require antibiotics. It is reasonable to manage these children expectantly with inpatient observation or close outpatient follow-up, depending on how well they appear, immunization status, and reliability of family. A pre–PCV-7 meta-analysis showed children with occult S pneumoniae bacteremia treated with parenteral antibiotics had a trend toward reduced incidence of pneumonia, meningitis, soft-tissue infection, or bone and joint infection compared with oral antibiotics. More than 90% of the studies in this meta-analysis were performed using IV or intramuscular (IM) ceftriaxone (typically 50 mg/kg/day) as the parenteral agent.$^{124}$ Ceftriaxone 100 mg/kg/day IV should be used if there is concern for meningitis.$^{125}$ For meningitis, consider administering corticosteroids such as dexamethasone before or with antibiotics, as they were shown in a 2015 meta-analysis to reduce hearing loss and neurologic sequelae.$^{126}$ Adding vancomycin for coverage of resistant organisms increases the rate of CSF sterilization at 24 hours.$^{127}$ If there is reason to suspect herpes simplex virus encephalitis, empiric IV acyclovir should be started early.$^{128}$

Well-appearing, otherwise healthy children with most infections such as cellulitis, UTI, AOM, pneumonia, pharyngitis, or enteritis (following local antibiogram) who have reliable caregivers who agree to 24- to 48-hour follow-up are often candidates for outpatient oral antibiotics.$^{59}$ However, if these children are unable to tolerate oral antibiotics or if there is a concern with the ability for them to be administered, then parenteral antibiotics are indicated. A frequent choice for UTI treatment is cephalexin. In these cases, dosing every 6 hours is indicated for adequate treatment.$^{129}$ (See Table 4.) There are some data supporting a shorter 2- to 4-day treatment course$^{130}$ compared to the standard 7- to 14-day course that the AAP recommends,$^{59}$ but this remains controversial.

AOM can be treated with high-dose amoxicillin 90 mg/kg/day orally in 2 divided doses for 10 days for patients aged <2 years, and 7 days for patients aged 2 to 5 years, with addition of beta-lactamase coverage (typically amoxicillin-clavulanate) if amoxicillin has been used in the past 30 days or there is history of recurrent AOM that does not respond to amoxicillin.$^{79,131}$ Amoxicillin-clavulanate is also indicated for those with otitis-conjunctivitis syndrome or suspicion of H influenzae for another reason.$^{79}$

Children with osteomyelitis, septic arthritis, meningitis, or sepsis should be admitted for parenteral antibiotics as guided by antibiogram. If there is no available antibiogram, empiric meningitis treatment should be provided as discussed previously. Empiric sepsis treatment begins with broad-spectrum antibiotics. A common choice is ceftriaxone 50 mg/kg IV, with addition of IV vancomycin dosed by pharmacy if there is suspicion for MRSA.17 Clindamycin 10 mg/kg IV every 8 hours, in lieu of vancomycin, may be an empiric choice for osteoarticular infections in areas where MRSA susceptibility to clindamycin is adequate.$^{40}$

For children with pneumonia who can be managed as outpatients, high-dose amoxicillin (90 mg/kg/day orally in 2 divided doses, max dose 2000 mg) is a first-line preferred agent, as it adequately covers most species of S pneumoniae, the most common cause of community-acquired pneumonia.$^{45}$ Newer recommendations suggest a 5-day treatment course is sufficient.$^{132}$ A macrolide should be used if the chest x-ray is consistent with an atypical organism. If influenza testing is positive or there is high suspicion for influenza infection, oseltamivir should be considered in high-risk children as soon as possible, as it is less effective after 48 hours of symptoms.$^{45}$