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A step-by-step approach to infant fever

September 9, 2016

Short Attention Span Summary

Uh-oh…feb neo
Febrile infants <90 days are one of the most challenging groups to manage.  Neonates <28 days are easy – full sepsis workup.  But what about 29-90 days?  Philadelphia Criteria would have us do a full sepsis workup on all <60 days and Boston Criteria on all <90 days, both including LP.  Rochester does not necessarily include CSF.  This new “step-by-step” protocol was prospectively compared to the Rochester criteria and Lab-score.  The step-by-step protocol is as follows:

Figure from article cited below.

Figure from article cited below.

What it showed
Prevalence of invasive bacterial infection (IBI) (defined as positive blood cx or CSF cx) was 4% (87/2185).  Note, IBI is not the same as serious bacterial infection (SBI), of which UTI is the most common.  Sensitivity and NPV for the Step-by-Step were 92% and 99.3%, respectively.  This beat the Rochester Criteria and trounced the Lab-score.  In terms of actual patients, 7 were missed with the step-by-step (0.7%), 16 missed with Rochester, and 35 with Lab-score.

Spoon Feed
We don’t have PCT yet, so I can’t use this protocol as written.  Neonates <28 days get the full monte, including CSF.  Note, I disagree with the author’s selection of age </= 21 days is high risk.  I like this rational, stepwise approach and not performing a LP on all kids < 90 days.  That’s overkill.

Dr. Nathan Mick with Maine Medical Center authored an amazing decision support module to walk you through the workup depending on the patient’s age.


Pediatrics. 2016 Jul 5. pii: e20154381. [Epub ahead of print]

Validation of the “Step-by-Step” Approach in the Management of Young Febrile Infants.

Gomez B1, Mintegi S2, Bressan S3, Da Dalt L4, Gervaix A5, Lacroix L5; European Group for Validation of the Step-by-Step Approach.

Author information:

1Pediatric Emergency Department, Cruces University Hospital, Bilbao, Spain; University of the Basque Country, Bilbao, Spain; borja.gomezcortes@osakidetza.eus.

2Pediatric Emergency Department, Cruces University Hospital, Bilbao, Spain; University of the Basque Country, Bilbao, Spain;

3Pediatric Emergency Unit – Department of Woman’s and Child Health, University of Padova, Italy;

4Ca’Foncello Hospital, Treviso, Italy; and.

5Pediatric Emergency Division, Geneva University Hospitals and University of Geneva, Geneva, Switzerland.



A sequential approach to young febrile infants on the basis of clinical and laboratory parameters, including procalcitonin, was recently described as an accurate tool in identifying patients at risk for invasive bacterial infection (IBI). Our aim was to prospectively validate the Step-by-Step approach and compare it with the Rochester criteria and the Lab-score.


Prospective study including infants ≤90 days with fever without source presenting in 11 European pediatric emergency departments between September 2012 and August 2014. The accuracy of the Step-by-Step approach, the Rochester criteria, and the Lab-score in identifying patients at low risk of IBI (isolation of a bacterial pathogen in a blood or cerebrospinal fluid culture) was compared.


Eighty-seven of 2185 infants (4.0%) were diagnosed with an IBI. The prevalence of IBI was significantly higher in infants classified as high risk or intermediate risk according to the Step by Step than in low risk patients. Sensitivity and negative predictive value for ruling out an IBI were 92.0% and 99.3% for the Step by Step, 81.6% and 98.3% for the Rochester criteria, and 59.8% and 98.1% for the Lab-score. Seven infants with an IBI were misclassified by the Step by Step, 16 by Rochester criteria, and 35 by the Lab-score.


We validated the Step by Step as a valuable tool for the management of infants with fever without source in the emergency department and confirmed its superior accuracy in identifying patients at low risk of IBI, compared with the Rochester criteria and the Lab-score.

Copyright © 2016 by the American Academy of Pediatrics.

PMID: 27382134 [PubMed – as supplied by publisher]

What are your thoughts?