Clinical Pathways
Clinical Pathways
>24 hr fever, high risk for urinary tract infection
>24 hr fever, high risk for urinary tract infection

>24 hr fever, high risk for urinary tract infection

View The Full Pathway

Action

Obtain urinalysis, urine culture (Class II)

Decision

Is urinalysis positive for infection?

Yes

  • If reliable caregiver and good oral intake, send home with antibiotics and recheck in 24-48 hr (Class II)
    • image

No

  • If reliable caregiver and good oral intake, send home without antibiotics and recheck in 24-48 hr (Class III)
  • Provide instructions to isolate/quarantine per CDC guidelines if COVID-positive (Class III)

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References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study is included in bold type following the references, where available. The most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.

  1. Le Doare K, Nichols AL, Payne H, et al. Very low rates of culture-confirmed invasive bacterial infections in a prospective 3-year population-based surveillance in southwest London. Arch Dis Child. 2014;99(6):526-531. (Prospective population study; 44,118 patients)
  2. Baraff LJ, Bass JW, Fleisher GR, et al. Practice guideline for the management of infants and children 0 to 36 months of age with fever without source. Agency for Health Care Policy and Research. Ann Emerg Med. 1993;22(7):1198-1210. (Society guidelines) DOI: 10.1016/s0196-0644(05)80991-6
  3. Mace SE, Gemme SR, Valente JH, et al. Clinical policy for well-appearing infants and children younger than 2 years of age presenting to the emergency department with fever. Ann Emerg Med. 2016;67(5):625-639. (Society guidelines)
  4. Jain A, Jain S, Rawat S. Emerging fungal infections among children: a review on its clinical manifestations, diagnosis, and prevention. J Pharm Bioallied Sci. 2010;2(4):314-320. (Systematic review)
  5. Pantell RH, Roberts KB, Adams WG, et al. Evaluation and management of well-appearing febrile infants 8 to 60 days old. Pediatrics. 2021;148(2):e2021052228. (Practice guideline) DOI: 10.1542/peds.2021-052228
  6. Giancane G, Consolaro A, Lanni S, et al. Juvenile idiopathic arthritis: diagnosis and treatment. Rheumatol Ther. 2016;3(2):187-207. (Review)
  7. Son MB, Sundel RP. Kawasaki disease. In: Petty RE, Laxer RM, Lindsley CB, et al., eds. Textbook of Pediatric Rheumatology. Philadelphia: Elsevier; 2016:467-483. (Textbook chapter)
  8. Sag E, Bilginer Y, Ozen S. Autoinflammatory diseases with periodic fevers. Curr Rheumatol Rep. 2017;19(7):41. (Review)
  9. Soon GS, Laxer RM. Approach to recurrent fever in childhood. Can Fam Physician. 2017;63(10):756-762. (Review)
  10. Takeuchi Y, Shigemura T, Kobayashi N, et al. Clinical features and new diagnostic criteria for the syndrome of periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis. Int J Rheum Dis. 2019;22(8):1489-1497. (Retrospective study; 257 patients)
  11. Léger J, Carel JC. Hyperthyroidism in childhood: causes, when and how to treat. J Clin Res Pediatr Endocrinol. 2013;5 Suppl 1(Suppl 1):50-56. (Review)
  12. Dayal R, Agarwal D. Fever in children and fever of unknown origin. Indian J Pediatr. 2016;83(1):38-43. (Review)
  13. Antoon JW, Potisek NM, Lohr JA. Pediatric fever of unknown origin. Pediatr Rev. 2015;36(9):380-390. (Systematic review)
  14. Antoon JW, Peritz DC, Parsons MR, et al. Etiology and resource use of fever of unknown origin in hospitalized children. Hosp Pediatr. 2018;8(3):135-140. (Retrospective study; 102 patients)
  15. Chow A, Robinson JL. Fever of unknown origin in children: a systematic review. World J Pediatr. 2011;7(1):5-10. (Systematic review)
  16. Chusid MJ. Fever of unknown origin in childhood. Pediatr Clin North Am. 2017;64(1):205-230. (Review)
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  21. Palladino L, Woll C, Aronson PL. Evaluation and management of the febrile young infant in the emergency department. Pediatr Emerg Med Pract. 2019;16(7):1-24. (Review)
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  25. Stoll ML, Rubin LG. Incidence of occult bacteremia among highly febrile young children in the era of the pneumococcal conjugate vaccine: a study from a children’s hospital emergency department and urgent care center. Arch Pediatr Adolesc Med. 2004;158(7):671-675. (Retrospective study; 329 patients)
  26. Bressan S, Berlese P, Mion T, et al. Bacteremia in feverish children presenting to the emergency department: a retrospective study and literature review. Acta Paediatr. 2012;101(3):271-277. (Retrospective study; 392 patients)
  27. Wilkinson M, Bulloch B, Smith M. Prevalence of occult bacteremia in children aged 3 to 36 months presenting to the emergency department with fever in the postpneumococcal conjugate vaccine era. Acad Emerg Med. 2009;16(3):220-225. (Retrospective study; 8408 patients)
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  32. Baraff LJ. Management of fever without source in infants and children. Ann Emerg Med. 2000;36(6):602-614. (Systematic review) DOI: 10.1067/mem.2000.110820
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  35. Sasaki A, Kunimoto M, Takeno S, et al. Influence of pneumococcal conjugate vaccines on acute otitis media in Japan. Auris Nasus Larynx. 2018;45(4):718-721. (Retrospective population study)
  36. Tawfik KO, Ishman SL, Altaye M, et al. Pediatric acute otitis media in the era of pneumococcal vaccination. Otolaryngol Head Neck Surg. 2017;156(5):938-945. (Retrospective population study)
  37. Hersh AL, Chambers HF, Maselli JH, et al. National trends in ambulatory visits and antibiotic prescribing for skin and soft-tissue infections. Arch Intern Med. 2008;168(14):1585-1591. (Retrospective population study)
  38. Lautz TB, Raval MV, Barsness KA. Increasing national burden of hospitalizations for skin and soft tissue infections in children. J Pediatr Surg. 2011;46(10):1935-1941. (Retrospective population study)
  39. Lopez MA, Cruz AT, Kowalkowski MA, et al. Trends in resource utilization for hospitalized children with skin and soft tissue infections. Pediatrics. 2013;131(3):e718-e725. (Cross-sectional study)
  40. Gigante A, Coppa V, Marinelli M, et al. Acute osteomyelitis and septic arthritis in children: a systematic review of systematic reviews. Eur Rev Med Pharmacol Sci. 2019;23(2 Suppl):145-158. (Systematic review)
  41. Dartnell J, Ramachandran M, Katchburian M. Haematogenous acute and subacute paediatric osteomyelitis: a systematic review of the literature. J Bone Joint Surg Br. 2012;94(5):584-595. (Systematic review)
  42. Kang SN, Sanghera T, Mangwani J, et al. The management of septic arthritis in children: systematic review of the English language literature. J Bone Joint Surg Br. 2009;91(9):1127-1133. (Systematic review)
  43. Murphy CG, van de Pol AC, Harper MB, et al. Clinical predictors of occult pneumonia in the febrile child. Acad Emerg Med. 2007;14(3):243-249. (Retrospective cross-sectional study; 1084 patients) DOI: 10.1197/j.aem.2006.08.022
  44. Shah S, Mathews B, Neuman MI, et al. Detection of occult pneumonia in a pediatric emergency department. Pediatr Emerg Care. 2010;26(9):615-621. (Prospective study; 1866 patients)
  45. Bradley JS, Byington CL, Shah SS, et al. Executive summary: the management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis. 2011;53(7):e25e76. (Guidelines) DOI: 10.1093/cid/cir625
  46. Rutman MS, Bachur R, Harper MB. Radiographic pneumonia in young, highly febrile children with leukocytosis before and after universal conjugate pneumococcal vaccination. Pediatr Emerg Care. 2009;25(1):1-7. (Retrospective study; 335 patients)
  47. Thigpen MC, Whitney CG, Messonnier NE, et al. Bacterial meningitis in the United States, 1998-2007. N Engl J Med. 2011;364(21):2016-2025. (Retrospective study; 3188 patients) DOI: 10.1056/NEJMoa1005384
  48. Shinjoh M, Yamaguchi Y, Iwata S. Pediatric bacterial meningitis in Japan, 2013-2015 -3-5 years after the wide use of Haemophilus influenzae type B and Streptococcus pneumoniae conjugated vaccines. J Infect Chemother. 2017;23(7):427-438. (Retrospective study; 407 patients)
  49. Alari A, Chaussade H, Domenech De Cellès M, et al. Impact of pneumococcal conjugate vaccines on pneumococcal meningitis cases in France between 2001 and 2014: a time series analysis. BMC Med. 2016;14(1):211. (Retrospective study; 5166 CSF cultures)
  50. Martin NG, Sadarangani M, Pollard AJ, et al. Hospital admission rates for meningitis and septicaemia caused by Haemophilus influenzae, Neisseria meningitidis, and Streptococcus pneumoniae in children in England over five decades: a population-based observational study. Lancet Infect Dis. 2014;14(5):397-405. (Retrospective population study)
  51. Ali A, Jafri RZ, Messonnier N, et al. Global practices of meningococcal vaccine use and impact on invasive disease. Pathog Glob Health. 2014;108(1):11-20. (Review)
  52. Kuppermann N, Malley R, Inkelis SH, et al. Clinical and hematologic features do not reliably identify children with unsuspected meningococcal disease. Pediatrics. 1999;103(2):E20. (Retrospective study; 45 patients)
  53. Wang VJ, Malley R, Fleisher GR, et al. Antibiotic treatment of children with unsuspected meningococcal disease. Arch Pediatr Adolesc Med. 2000;154(6):556-560. (Retrospective study; 58 patients)
  54. Alpern ER, Alessandrini EA, Bell LM, et al. Occult bacteremia from a pediatric emergency department: current prevalence, time to detection, and outcome. Pediatrics. 2000;106(3):505-511. (Retrospective study; 5901 patients)
  55. Herz AM, Greenhow TL, Alcantara J, et al. Changing epidemiology of outpatient bacteremia in 3-to 36-month-old children after the introduction of the heptavalent-conjugated pneu mococcal vaccine. Pediatr Infect Dis J. 2006;25(4):293-300. (Retrospective study; 37,133 blood cultures)
  56. Sard B, Bailey MC, Vinci R. An analysis of pediatric blood cultures in the postpneumococcal conjugate vaccine era in a community hospital emergency department. Pediatr Emerg Care. 2006;22(5):295-300. (Retrospective study; 2971 blood cultures)
  57. Farnham AC, Zimmerman CM, Papadouka V, et al. Invasive pneumococcal disease following the introduction of 13-valent conjugate vaccine in children in New York City from 2007 to 2012. JAMA Pediatr. 2015;169(7):646-652. (Retrospective study; 468 cases)
  58. Committee on Quality Improvement: Subcommittee on Urinary Tract Infection. Practice parameter: the diagnosis, treatment, and evaluation of the initial urinary tract infection in febrile infants and young children. Pediatrics. 1999;103(4):843-852. (Guideline)
  59. Roberts KB. Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics. 2011;128(3):595-610. (Society guidelines) DOI: 10.1542/peds.2011-1330
  60. Subcommittee on Urinary Tract Infection. Reaffirmation of AAP clinical practice guideline: the diagnosis and management of the initial urinary tract infection in febrile infants and young children 2-24 months of age. Pediatrics. 2016;138(6):e20163026. (Society guidelines)
  61. Shaikh N, Morone NE, Bost JE, et al. Prevalence of urinary tract infection in childhood: a meta-analysis. Pediatr Infect Dis J. 2008;27(4):302-308. (Meta-analysis; 22,919 patients)
  62. Courchia B, Ramirez D, Rauch DA. Changes in urinary tract infection hospitalizations post 2011 revised American Academy Pediatrics Guidelines. Clin Pediatr (Phila). 2018;57(12):1409-1413. (Retrospective population study)
  63. Schlechter Salinas AK, Hains DS, Jones T, et al. Testing for urinary tract infection in the influenza/respiratory syncytial virus-positive febrile infant aged 2 to 12 months. Pediatr Emerg Care. 2019;35(10):666-670. (Retrospective study; 1724 patients)
  64. Shane AL, Mody RK, Crump JA, et al. 2017 Infectious Diseases Society of America Clinical Practice Guidelines for the diagnosis and management of infectious diarrhea. Clin Infect Dis. 2017;65(12):1963-1973. (Practice guideline)
  65. Browne AJ, Kashef Hamadani BH, Kumaran EAP, et al. Drug-resistant enteric fever worldwide, 1990 to 2018: a systematic review and meta-analysis. BMC Med. 2020;18(1):1. (Meta-analysis; 124,347 microbe isolates)
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  67. Gausche-Hill M, Eckstein M, Horeczko T, et al. Paramedics accurately apply the pediatric assessment triangle to drive management. Prehosp Emerg Care. 2014;18(4):520-530. (Prospective study; 1168 patients)
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  74. Li YW, Zhou LS, Li X. Accuracy of tactile assessment of fever in children by caregivers: a systematic review and meta-analysis. Indian Pediatr. 2017;54(3):215-221. (Meta-analysis; 3625 patients)
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  76. Bang A, Chaturvedi P. Yale Observation Scale for prediction of bacteremia in febrile children. Indian J Pediatr. 2009;76(6):599-604. (Prospective study; 219 patients)
  77. Lye PS, Densmore EM. Fever. In: Kliegman RM, Lye PS, Bordini BJ, et al, eds. Nelson Pediatric Symptom-Based Diagnosis: Elsevier; 2018:701-725. (Book chapter)
  78. Thompson M, Coad N, Harnden A, et al. How well do vital signs identify children with serious infections in paediatric emergency care? Arch Dis Child. 2009;94(11):888-893. (Prospective study; 700 patients)
  79. Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media. Pediatrics. 2013;131(3):e964-e999. (Society guidelines)
  80. Shriner A, Wilkie L. Pediatric cellulitis: a red-hot concern. Pediatr Ann. 2017;46(7):e265-e269. (Systematic review)
  81. Shah SN, Bachur RG, Simel DL, et al. Does this child have pneumonia?: The rational clinical examination systematic review. JAMA. 2017;318(5):462-471. (Meta-analysis; 13,833 patients)
  82. Amarilyo G, Alper A, Ben-Tov A, et al. Diagnostic accuracy of clinical symptoms and signs in children with meningitis. Pediatr Emerg Care. 2011;27(3):196-199. (Prospective study; 108 patients)
  83. Simon AE, Lukacs SL, Mendola P. Emergency department laboratory evaluations of fever without source in children aged 3 to 36 months. Pediatrics. 2011;128(6):e1368-e1375. (Retrospective study)
  84. Madsen KA, Bennett JE, Downs SM. The role of parental preferences in the management of fever without source among 3- to 36-month-old children: a decision analysis. Pediatrics. 2006;117(4):1067-1076. (Decision analysis)
  85. Dunnick J, Taft M, Tisherman RT, et al. Association of bacteremia with vaccination status in children aged 2 to 36 months. J Pediatr. 2021;232:207-213. (Retrospective cohort study; 4742 patients)
  86. Nijman RG, Moll HA, Smit FJ, et al. C-reactive protein, procalcitonin and the lab-score for detecting serious bacterial infections in febrile children at the emergency department: a prospective observational study. Pediatr Infect Dis J. 2014;33(11):e273- e279. (Prospective study; 1084 patients)
  87. Trippella G, Galli L, de Martino M, et al. Inflammatory biomarkers to guide diagnostic and therapeutic decisions in children presenting with fever without apparent source. J Chemother. 2018;30(5):255-265. (Systematic review; 13 studies)
  88. Pratt A, Attia MW. Duration of fever and markers of serious bacterial infection in young febrile children. Pediatr Int. 2007;49(1):31-35. (Prospective study; 128 patients)
  89. Manzano S, Bailey B, Gervaix A, et al. Markers for bacterial infection in children with fever without source. Arch Dis Child. 2011;96(5):440-446. (Prospective study; 328 patients)
  90. Andreola B, Bressan S, Callegaro S, et al. Procalcitonin and C-reactive protein as diagnostic markers of severe bacterial infections in febrile infants and children in the emergency department. Pediatr Infect Dis J. 2007;26(8):672-677. (Prospective study; 408 patients)
  91. Manzano S, Bailey B, Girodias JB, et al. Impact of procalcitonin on the management of children aged 1 to 36 months presenting with fever without source: a randomized controlled trial. Am J Emerg Med. 2010;28(6):647-653. (Randomized controlled trial; 384 patients)
  92. Yang YJ, Huang MC, Wang SM, et al. Analysis of risk factors for bacteremia in children with nontyphoidal Salmonella gastroenteritis. Eur J Clin Microbiol Infect Dis. 2002;21(4):290-293. (Retrospective study; 456 infants and children)
  93. Lee CM, Lee MS, Yang TL, et al. Clinical features and risk factors associated with bacteremia of nontyphoidal salmonellosis in pediatric patients, 2010-2018. J Formos Med Assoc. 2021;120(1 Pt 1):196-203. (Retrospective study; 569 isolates)
  94. Raucher HS, Eichenfield AH, Hodes HL. Treatment of Salmonella gastroenteritis in infants. The significance of bacteremia. Clin Pediatr (Phila). 1983;22(9):601-604. (Case series; 20 patients)
  95. Nguyen A, Kan JH, Bisset G, et al. Kocher criteria revisited in the era of MRI: how often does the Kocher criteria identify underlying osteomyelitis? J Pediatr Orthop. 2017;37(2):e114-e119. (Retrospective study; 71 patients)
  96. Gorelick MH, Shaw KN. Clinical decision rule to identify febrile young girls at risk for urinary tract infection. Arch Pediatr Adolesc Med. 2000;154(4):386-390. (Prospective study; 1469 patients)
  97. Hsu PC, Chen SJ. Obesity and risk of urinary tract infection in young children presenting with fever. Medicine (Baltimore). 2018;97(49):e13006. (Retrospective study; 472 patients)
  98. Leung AKC, Wong AHC, Leung AAM, et al. Urinary tract infection in children. Recent Pat Inflamm Allergy Drug Discov. 2019;13(1):2-18. (Systematic review)
  99. May OW. Urine collection methods in children: which is the best? Nurs Clin North Am. 2018;53(2):137-143. (Review)
  100. Mulcrone AE, Parikh M, Ahmad FA. Reducing infant catheterization in the emergency department through clean-catch urine collection. J Am Coll Emerg Physicians Open. 2020;1(6):1533-1541. (Retrospective study; 334 patients)
  101. Tebruegge M, Pantazidou A, Clifford V, et al. The age-related risk of co-existing meningitis in children with urinary tract infection. PLoS One. 2011;6(11):e26576. (Retrospective study; 748 cases)
  102. Megged O. Bacteremic vs nonbacteremic urinary tract infection in children. Am J Emerg Med. 2017;35(1):36-38. (Retrospective study; 464 cases)
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  104. Friedman JN, Davis T, Somaskanthan A, et al. Avoid doing chest x rays in infants with typical bronchiolitis. BMJ. 2021;375:e064132. (Review)
  105. Balk DS, Lee C, Schafer J, et al. Lung ultrasound compared to chest x-ray for diagnosis of pediatric pneumonia: a meta-analysis. Pediatr Pulmonol. 2018;53(8):1130-1139. (Meta-analysis; 1510 patients)
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  107. Volpicelli G, Elbarbary M, Blaivas M, et al. International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med. 2012;38(4):577-591. (Review)
  108. Riccabona M. Ultrasound of the chest in children (mediastinum excluded). Eur Radiol. 2008;18(2):390-399. (Review)
  109. Forward KR, Fewer HD, Stiver HG. Cerebrospinal fluid shunt infections. A review of 35 infections in 32 patients. J Neurosurg. 1983;59(3):389-394. (Retrospective study; 32 patients)
  110. Odio C, McCracken GH Jr, Nelson JD. CSF shunt infections in pediatrics. A seven-year experience. Am J Dis Child. 1984;138(12):1103-1108. (Retrospective study; 297 patients)
  111. Oluwabusi T, Sood SK. Update on the management of simple febrile seizures: emphasis on minimal intervention. Curr Opin Pediatr. 2012;24(2):259-265. (Guidelines)
  112. Najaf-Zadeh A, Dubos F, Hue V, et al. Risk of bacterial meningitis in young children with a first seizure in the context of fever: a systematic review and meta-analysis. PLoS One. 2013;8(1):e55270. (Meta-analysis; 1869 patients)
  113. Hom J, Medwid K. The low rate of bacterial meningitis in children, ages 6 to 18 months, with simple febrile seizures. Acad Emerg Med. 2011;18(11):1114-1120. (Case reports; 2 studies, 150 children)
  114. Kimia AA, Capraro AJ, Hummel D, et al. Utility of lumbar puncture for first simple febrile seizure among children 6 to 18 months of age. Pediatrics. 2009;123(1):6-12. (Retrospective study; 704 patients)
  115. Hamilton JL, John SP. Evaluation of fever in infants and young children. Am Fam Physician. 2013;87(4):254-260. (Review)
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  117. Spagnuolo PJ, Zhang M, Xu Y, et al. Effects of antiviral treatment on influenza-related complications over four influenza seasons: 2006-2010. Curr Med Res Opin. 2016;32(8):1399-1407. (Retrospective study; >1,500,000 patients)
  118. Shi L, Loveless M, Spagnuolo P, et al. Antiviral treatment of influenza in children: a retrospective cohort study. Adv Ther. 2014;31(7):735-750. (Retrospective cohort study; 797,284 patients)
  119. Schnell J, Schroeder L, Sinclair K, et al. The effect of early knowledge of respiratory syncytial virus positivity on medical decision making and throughput time within the pediatric emergency department. Pediatr Emerg Care. 2020;36(3):134-137. (Retrospective study; 899 patients)
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