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Guideline Summary
Guideline Title
Evidence-based care guideline for fever of uncertain source in infants 60 days of age or less.
Bibliographic Source(s)
Cincinnati Children's Hospital Medical Center. Evidence-based care guideline for fever of uncertain source in infants 60 days of age or less. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2010 Oct 27. 15 p. [51 references]
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Cincinnati Children's Hospital Medical Center. Evidence based clinical protocol guideline for fever of uncertain source in infants 60 days of age or less. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2003 Jun. 12 p.

Scope

Disease/Condition(s)

Fever of uncertain source

Note: A rectal temperature to establish fever is ≥38° C for the purpose of this guideline.

Guideline Category
Diagnosis
Evaluation
Management
Risk Assessment
Treatment
Clinical Specialty
Emergency Medicine
Family Practice
Infectious Diseases
Pediatrics
Intended Users
Advanced Practice Nurses
Health Care Providers
Nurses
Patients
Physician Assistants
Physicians
Guideline Objective(s)
  • To identify appropriate diagnostic studies
  • To identify appropriate antimicrobial therapy
  • To improve the efficiency of care
  • To improve parent and family satisfaction with care
Target Population

Inclusions

Infants, 60 days of age or less, presenting as outpatients with a fever of uncertain source

Exclusions

  • Infants with underlying disorders that affect their immunity or might otherwise increase their risk for serious infections
  • Infants on current antimicrobial therapy
  • Infants who have received an immunization within 48 hours
  • Infants presenting with seizures
  • Infants requiring intensive care management
Interventions and Practices Considered

Risk Assessment/Diagnosis

  1. Clinical assessment, including rectal temperatures, history, and physical examination
  2. Laboratory studies, including complete blood count (CBC), urinalysis, cerebrospinal fluid (CSF), and stool studies
  3. Decision to admit to hospital or maintain outpatient care based on risk factors

Management/Treatment

  1. Antibiotics for presumed serious bacterial infection
    • Ampicillin
    • Cefotaxime (Clarforan)
    • Ceftriaxone (Rocephin)
    • Gentamicin
    • Vancomycin
  2. Antiviral (acyclovir) for presumed neonatal herpes simplex virus (HSV) infection
  3. Discharge criteria
  4. Follow-up
  5. Consults and referrals
  6. Education of parent and family
Major Outcomes Considered
  • Risk for serious bacterial infection (SBI)
  • Sensitivity, specificity, and diagnostic value of clinical assessments and diagnostic tests
  • Risk for herpes simplex viral (HSV) infection

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

To select evidence for critical appraisal by the group for this guideline, the Medline, EmBase and the Cochrane databases were searched for dates of January, 2003 to February, 2010 to generate an unrefined, "combined evidence" database using a search strategy focused on answering clinical questions relevant to fever of uncertain source and employing a combination of Boolean searching on human-indexed thesaurus terms (MeSH headings using an OVID Medline interface) and "natural language" searching on human-indexed thesaurus terms (MeSH headings using an OVID Medline interface) and "natural language" searching on words in the title, abstract, and indexing terms. The citations were reduced by: eliminating duplicates, review articles, non-English articles, and adult articles. The resulting abstracts were reviewed by a methodologist to eliminate low quality and irrelevant citations. During the course of the guideline development, additional clinical questions were generated and subjected to the search process, and some relevant review articles were identified. December, 2002 was the last date for which literature was reviewed for the previous version of this guideline. The details of that review strategy are not documented. However, all previous citations were reviewed for appropriateness to this revision.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Table of Evidence Levels

Quality Level Definition
1a† or 1b† Systematic review, meta-analysis, or meta-synthesis of multiple studies
2a or 2b Best study design for domain
3a or 3b Fair study design for domain
4a or 4b Weak study design for domain
5 Other: General review, expert opinion, case report, consensus report, or guideline

†a = good quality study; b = lesser quality study

Methods Used to Analyze the Evidence
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

The recommendations contained in this guideline were formulated by an interdisciplinary working group which performed systematic search and critical appraisal of the literature, using the Table of Evidence Levels described in the "Rating Scheme for the Strength of the Evidence" field, and examined current local clinical practices.

Recommendations have been formulated by a consensus process directed by best evidence, patient and family preference and clinical expertise. During formulation of these recommendations, the team members have remained cognizant of controversies and disagreements over the management of these patients. They have tried to resolve controversial issues by consensus where possible and, when not possible, to offer optional approaches to care in the form of information that includes best supporting evidence of efficacy for alternative choices.

Rating Scheme for the Strength of the Recommendations

Table of Recommendation Strength

Strength Definition
"Strongly recommended" There is consensus that benefits clearly outweigh risks and burdens (or vice-versa for negative recommendations).
"Recommended" There is consensus that benefits are closely balanced with risks and burdens.
No recommendation made There is a lack of consensus to direct development of a recommendation.
Dimensions: In determining the strength of a recommendation, the development group makes a considered judgment in a consensus process that incorporates critically appraised evidence, clinical experience, and other dimensions as listed below.
  1. Grade of the Body of Evidence
  2. Safety/Harm
  3. Health benefit to the patients (direct benefit)
  4. Burden to patient of adherence to recommendation (cost, hassle, discomfort, pain, motivation, ability to adhere, time)
  5. Cost-effectiveness to healthcare system (balance of cost/savings of resources, staff time, and supplies based on published studies or onsite analysis)
  6. Directness (the extent to which the body of evidence directly answers the clinical question [population/problem, intervention, comparison, outcome])
  7. Impact on morbidity/mortality or quality of life
Cost Analysis

The guideline developers reviewed published cost analyses.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

The guidelines have been reviewed and approved by clinical experts not involved in the development process, distributed to senior management, and other parties as appropriate to their intended purposes.

Recommendations

Major Recommendations

The strength of the recommendation (strongly recommended, recommended, and no recommendation) and quality of the evidence (1a-5) are defined at the end of the "Major Recommendations" field.

Assessment and Diagnosis

Clinical Assessment

  1. It is recommended that a rectal temperature be measured to establish fever ≥38° C for the purpose of this guideline (Claudius & Baraff, 2010 [5b]).

    Note 1: Patients who had a reliable rectal temperature measured at home undergo the same evaluation as if the temperature was measured in the office or emergency department (Claudius & Baraff, 2010 [5b]; Ishimine, 2007 [5b]).

    Note 2: Parental report of fever via palpation is unreliable as a sole method of determining fever (Katz-Sidlow, Rowberry, & Ho, 2009 [4b]; Callanan, 2003 [4b]).

    Note 3: A response to antipyretic medication does not change the likelihood of an infant having a serious bacterial infection (American College of Emergency Physicians Clinical Policies Committee, 2003 [5a]).

  1. It is recommended that a clinical assessment include a thorough history and physical exam (Baraff, 2008 [5b]).

    Note: Include questions about recent symptoms, vaccinations, exposure to sick contacts, and the child's birth history in the patient history (Thompson et al., 2006 [4a]; Sur & Bukont, 2007 [5b]).

Laboratory Studies: Neonates

  1. It is recommended that the following laboratory studies be performed in neonates with fever of uncertain source (FUS) (Bilavsky et al., 2009 [3b]; Gomez et al., 2010 [4b]; American College of Emergency Physicians Clinical Policies Committee, 2003 [5a]; Baraff, 2008 [5b]; Sur & Bukont, 2007 [5b]):
    • Complete blood count (CBC), differential, blood culture
    • Urinalysis (UA) and urine culture

    Note: Urethral catheterization and, although rarely performed, suprapubic aspiration are preferred methods for obtaining urine specimens. High rates of contamination occur with bagged specimens (American College of Emergency Physicians Clinical Policies Committee, 2003 [5a])

    • Cerebrospinal fluid (CSF) studies:
      Tube 1: protein and glucose
      Tube 2: culture, sensitivity, Gram stain
      Tube 3: cell count and differential
      Tube 4: hold for additional studies
    • Stool culture if diarrhea is present (Ishimine, 2007 [5b])
  1. It is recommended that CSF herpes simplex virus (HSV) polymerase chain reaction (PCR) testing not be routinely performed in neonates who present with FUS and no other evidence of an HSV infection (Caviness et al., "Cost-effectiveness," 2008 [1a]; Shah et al., 2010 [4b]; Local Consensus [5b]).
  2. It is recommended that CSF HSV PCR be considered in neonates with CSF pleocytosis and a negative Gram stain (Caviness et al., "Cost-effectiveness," 2008 [1a]; Caviness et al., "The prevalence," 2008 [4b]; Local Consensus [5b]).

Laboratory Studies: Young Infants 29-60 Days of Age

  1. It is recommended that the following laboratory studies be performed in young infants 29 to 60 days of age with FUS (Bilavsky et al., 2009 [3b]; Gomez et al., 2010 [4b]; Kourtis, Sullivan, & Sathian, 2004 [5a]; American College of Emergency Physicians Clinical Policies Committee, 2003 [5a]; Ishimine, 2007 [5b]).
    • Complete blood count, differential, blood culture
    • Urinalysis and urine culture

    Note: Urethral catheterization and, although rarely performed, suprapubic aspiration are preferred methods for obtaining urine specimens. High rates of contamination occur with bagged specimens (American College of Emergency Physicians Clinical Policies Committee, 2003 [5a]).

    • Stool studies for white blood cell (WBC) count and culture if diarrhea is present (Ishimine, 2007 [5b]).

    Note: C-reactive protein (CRP) and procalcitonin (PCT) have been studied in infants less than 90 days presenting with fever of uncertain source (Maniaci et al., 2008 [3a]; Bilavsky et al., 2009 [3b]; Olaciregui et al., 2009 [4a]). Inclusion in a diagnostic evaluation of FUS does not improve our confidence in ruling out serious bacterial infections (SBI) at this time. See appendix for likelihood ratios from diagnostic studies evaluated in the original guideline document.

  1. It is recommended that delaying or omitting a lumbar puncture (LP) for CSF analyses be considered in young infants 29 to 60 days of age with FUS who meet all applicable low-risk clinical and laboratory criteria (See Table 2 below) (Huppler, Eickhoff, & Wald, 2010 [1b]; Sur & Bukont, 2007 [5b]; Local Consensus [5b]).

    Note 1: If antimicrobial therapy will be initiated in infants who meet low-risk criteria, CSF specimens need to be collected prior to treatment. See Note 2 below for details of CSF analyses.

    Note 2: If all applicable low risk clinical and laboratory criteria are not met, CSF analyses include:
    Tube 1: protein and glucose
    Tube 2: culture, sensitivity, Gram stain
    Tube 3: cell count and differential
    Tube 4: hold for additional studies

Table 2: Low-Risk Criteria (Garra, Cunningham, & Crain, 2005 [2b]; Gomez et al., 2010 [4b]; Baraff, 2008 [5b]; Dobson et al., 2008 [5b])
Low-risk Clinical Criteria
  • Well-appearing
  • Previously healthy
  • No focal source of infection
Low-risk Laboratory Criteria
Urinalysis
  • ≤10 WBC/hpf
  • No bacteria on Gram stain
Complete blood count (CBC)
  • WBC 5,000 to 15,000/mm3
  • ≤1,500 band cells/mm3
Chest radiograph (if obtained)
  • No evidence of discrete infiltrate
Stool smear (when diarrhea is present)
  • Negative for blood
  • ≤5 WBC/hpf

hpf=high-power field, WBC=white blood cells

Note: The likelihood ratio for ruling-out serious bacterial infections (SBI) in patients who meet low-risk clinical and laboratory criteria is 0.08 (Garra, Cunningham, & Crain, 2005 [2b]). See the appendix in the original guideline document for further information.

  1. It is recommended that testing for enteroviruses (EV), human herpesvirus 6, influenza A and B viruses, rotavirus, respiratory syncytial virus, and Treponema pallidum be selectively considered for infants with fever (Benito-Fernandez et al., 2006 [3a]; Byington et al., 2004 [3a]; Rittichier et al., 2005 [3b]; Byington et al., 2002 [4b]).

    Note: PCR testing of both blood and CSF for enterovirus increased the diagnostic yield of enterovirus infections by ~20% in one study (Rittichier et al., 2005 [3b]).

Radiology Studies

  1. It is recommended that a chest x-ray be performed in neonates and young infants 29 to 60 days of age who manifest one or more of the following clinical findings: tachypnea >60 breaths/min, crackles in the chest, retractions, nasal flaring, cyanosis, or oxygen saturation ≤95% (National Collaborating Centre for Women's and Children's Health, 2007 [5a]).

Management

Admission Criteria

  1. It is recommended that all neonates with FUS be admitted to the hospital (Gomez et al., 2010 [4b]; Claudius & Baraff, 2010 [5b]; Baraff, 2008 [5b]; Ishimine, 2007 [5b]; Sur & Bukont, 2007 [5b]).
  2. It is recommended that young infants 29 to 60 days of age with FUS be admitted to the hospital when all relevant low risk clinical and laboratory criteria are not met (Table 2 above) and/or social or family concerns (e.g., transportation problems, lack of resources for prompt medical follow-up) are present (Ishimine, 2007 [5b]).
  3. It is recommended that outpatient management of young infants 29 to 60 days of age with FUS be considered if all the following conditions are present (Huppler, Eickhoff, & Wald, 2010 [1b]; Condra et al., 2010 [3b]; Baraff, 2008 [5b]; Local Consensus [5b]):
    • Low-risk clinical and laboratory criteria have been met (see Table 2 above)
    • Available reliable follow-up in 12-24 hours
    • Healthcare provider(s) confident that parent will use appropriate observational and follow-up skills
    • Primary care physician (PCP) and family agree with plan of care

Medications: Neonates

  1. It is recommended that neonates with FUS be treated with intravenous (IV) ampicillin plus a 3rd generation cephalosporin or gentamicin pending culture results (Brown, Burns, & Cummings, 2002 [1b]; Baraff, 2008 [5b]; Dobson et al., 2008 [5b]; Ishimine, 2007 [5b]).

    See Table 3 in the original guideline document for a summary of recommended doses for antibiotics.

  1. It is recommended that vancomycin rather than ampicillin be considered in neonates with FUS at risk for S. aureus (Byington et al., 2003 [3a]; Local Consensus [5b]).
  2. It is recommended that treatment for HSV be considered in neonates with FUS, CSF pleocytosis, and a negative Gram stain until an alternative diagnosis is established or CSF PCR is negative for HSV (Caviness et al., "Cost-effectiveness," 2008 [1a]; Claudius & Baraff, 2010 [5b]; Baraff, 2008 [5b]). See Table 3 in the original guideline document for dosing of acyclovir.

Medications: Young Infants 29 to 60 Days of Age

  1. It is recommended that young infants 29 to 60 days of age with FUS who do not meet low risk criteria (Table 2 above) be treated with a 3rd generation cephalosporin pending culture results (Byington et al., 2003 [3a]).
  2. It is recommended that intravenous (IV) ampicillin be considered as an addition to the antibiotic regimen for febrile infants 29 to 60 days of age who are severely ill or who have findings suggestive of urinary tract infection to assure coverage for rare organisms such as Listeria monocytogenes, gram-positive cocci or enterococcus (Brown, Burns, & Cummings, 2002 [1b]; Byington et al., 2003 [3a]).
  3. It is recommended that vancomycin be considered in febrile young infants 29 to 60 days of age at risk for S. aureus (Byington et al., 2003 [3a]; Local Consensus [5b]).
  4. It is recommended that a 3rd generation cephalosporin (such as ceftriaxone) be considered for young infants 29 to 60 days of age managed as outpatients after a LP is performed (Dobson et al., 2008 [5b]).

Monitoring

  1. It is recommended that fluid status be carefully monitored in all patients (Local Consensus [5b]).

    Note: Especially for patients on gentamicin and/or acyclovir, fluid replacement may be needed if the infant is dehydrated due to a risk of renal toxicity.

  1. It is recommended that the duration of initial treatment cover a period of 36 hours until culture results are available (Local Consensus [5b]).

    Note 1: Cultures must be checked after a true minimum incubation period of 36 hours, which begins when the inoculated culture is placed in the incubator.

    Note 2: Approximately 90% of bacterial pathogens are identified within the first 24 hours of incubation (Byington et al., 2004 [3a]).

    Note 3: The probability of identifying serious bacterial infections (SBIs) in febrile infants (28-90 days) after 24 hours is about 1.1% among all patients and 0.3% among low risk patients (Kaplan et al., 2000 [4b]).

    Note 4: In blood cultures of infants 0-6 months of age, mean time to positivity for true pathogens is about 17.5 hours and for contaminants is about 27.9 hours (McGowan, Foster, & Coffin, 2000 [4a]). Median time to positivity for urine and CSF cultures are 16 and 18 hours, respectively, in febrile infants age 28-90 days (Kaplan et al., 2000 [4b]).

  1. It is recommended that in patients with FUS who are not responding to antimicrobial therapy, the clinician consider additional evaluation and treatment options, including:
    • Alternative antimicrobial therapy for resistant organisms (Byington et al., 2003 [3a]; Local Consensus [5b])
    • (In neonates only) CSF HSV PCR (if not completed previously) and empiric treatment with acyclovir (Caviness, Demmler, & Selwyn, 2008 [4b]; Sur & Bukont, 2007 [5b])

Discharge Criteria

  1. It is recommended that discharge be considered in patients with negative cultures after a true minimum incubation period of 36 hours (Local Consensus [5b]). See Table 4 for discharge criteria.

Table 4: Discharge Criteria

  • Well-appearing
  • Eating well
  • Antimicrobial therapies complete or can be continued in the home
  • Culture results negative
  • Infant observed without antibacterial treatment is well-appearing at 24 hours
  • Family:
    1. Has participated in the discharge planning and decision process
    2. Understands and agrees to any prescribed therapies or follow-up needs
    3. Confident in ability to care for infant at home
  • Home environment considered appropriate for continuing care
  • Follow-up physician:
    1. Identified
    2. Has participated in generating the discharge plan
    3. Agrees with the discharge plan

Follow-up

  1. It is recommended that young infants 29 to 60 days of age managed as outpatients be examined by their health care provider within 12 to 24 hours for follow-up and a second dose of ceftriaxone (if applicable) (Dobson et al., 2008 [5b]).

Consults and Referrals

  1. It is recommended that a consult with an infectious disease specialist be considered for (Local Consensus [5b]):
    • An unusual presentation or clinical course of disease
    • Questions regarding acyclovir treatment
  2. It is recommended that a consult with Lactation Services be considered for breastfed patients who are feeding poorly (Local Consensus [5b]).

Education

  1. It is recommended that parent and family education include the following (Local Consensus [5b]):
    • Knowledge of illness
    • Worrisome signs to report to medical care provider
    • When and how to measure child's temperature
    • Administration of medications
    • Nutrition and fluids

Definitions:

Table of Evidence Levels

Quality Level Definition
1a† or 1b† Systematic review, meta-analysis, or meta-synthesis of multiple studies
2a or 2b Best study design for domain
3a or 3b Fair study design for domain
4a or 4b Weak study design for domain
5 Other: General review, expert opinion, case report, consensus report, or guideline

†a = good quality study; b = lesser quality study

Table of Recommendation Strength

Strength Definition
"Strongly recommended" There is consensus that benefits clearly outweigh risks and burdens (or vice-versa for negative recommendations).
"Recommended" There is consensus that benefits are closely balanced with risks and burdens.
No recommendation made There is a lack of consensus to direct development of a recommendation.
Dimensions: In determining the strength of a recommendation, the development group makes a considered judgment in a consensus process that incorporates critically appraised evidence, clinical experience, and other dimensions as listed below.
  1. Grade of the Body of Evidence
  2. Safety/Harm
  3. Health benefit to the patients (direct benefit)
  4. Burden to patient of adherence to recommendation (cost, hassle, discomfort, pain, motivation, ability to adhere, time)
  5. Cost-effectiveness to healthcare system (balance of cost/savings of resources, staff time, and supplies based on published studies or onsite analysis)
  6. Directness (the extent to which the body of evidence directly answers the clinical question [population/problem, intervention, comparison, outcome])
  7. Impact on morbidity/mortality or quality of life
Clinical Algorithm(s)

Clinical algorithms are provided in the original guideline document for:

  • Managing Fever of Uncertain Source in Neonates (Age 0 to 28 Days)
  • Managing Fever of Uncertain Source in Young Infants (Age 29 to 60 Days)

Evidence Supporting the Recommendations

References Supporting the Recommendations
Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate diagnosis and treatment of fever of uncertain source in infants 60 days of age or less to improve the efficiency of care and parent and family satisfaction

Potential Harms

Fluid replacement may be needed, especially for patients on gentamicin and/or acyclovir, if the infant is dehydrated due to a risk of renal toxicity.

Contraindications

Contraindications

Ceftriaxone is contraindicated in neonates with hyperbilirubinemia and in neonates requiring or who may require intravenous (IV) calcium-containing solutions.

Qualifying Statements

Qualifying Statements

These recommendations result from review of literature and practices current at the time of their formulations. This guideline does not preclude using care modalities proven efficacious in studies published subsequent to the current revision of this document. This document is not intended to impose standards of care preventing selective variances from the recommendations to meet the specific and unique requirements of individual patients. Adherence to this guideline is voluntary. The clinician in light of the individual circumstances presented by the patient must make the ultimate judgment regarding the priority of any specific procedure.

Implementation of the Guideline

Description of Implementation Strategy

Tools to assist in the effective dissemination and implementation of the guideline may be available online at http://www.cincinnatichildrens.org/svc/alpha/h/health-policy/ev-based/default.htm External Web Site Policy. Experience with the implementation of earlier publications of this guideline has provided learnings which have been incorporated into this revision.

Implementation Tools
Chart Documentation/Checklists/Forms
Clinical Algorithm
Patient Resources
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Cincinnati Children's Hospital Medical Center. Evidence-based care guideline for fever of uncertain source in infants 60 days of age or less. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2010 Oct 27. 15 p. [51 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
1998 May 15 (revised 2010 Oct 27)
Guideline Developer(s)
Cincinnati Children's Hospital Medical Center - Hospital/Medical Center
Source(s) of Funding

Cincinnati Children's Hospital Medical Center

Guideline Committee

FUS Team 2010

Composition of Group That Authored the Guideline

Community Physicians: Shana Alexander, MD, Chair

Cincinnati Children's Hospital Medical Center (CCHMC) Physicians: Ryan Baker, MD, Chief Resident; Patricia Chambers, MD, Emergency Medicine; Elena Duma, MD, Emergency Medicine; *Michael Gerber, MD, Infectious Disease; Jennifer O'Toole, MD, General Pediatrics; *Bob Siegel, MD, Heart Institute; Ndidi Unaka, MD, Chief Resident

Patient Services: Karen Tucker, RN, MSN, A6 South; *Michelle Widecan, RN, MSN, Emergency Medicine

Laboratory: *Joel Mortensen, PhD

Pharmacist: *Dawn Butler, PharmD

Division of Health Policy & Clinical Effectiveness Support: *Eloise Clark, MPH, Lead Guidelines Program Administrator; *Edward Donovan, MD, Child Policy Research Center; Betsy List, MPH, RN, Facilitator

*Member of previous FUS guideline development Team

Financial Disclosures/Conflicts of Interest

The guideline was developed without external funding. All Team Members and Clinical Effectiveness support staff listed have declared whether they have any conflict of interest and none were identified.

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Cincinnati Children's Hospital Medical Center. Evidence based clinical protocol guideline for fever of uncertain source in infants 60 days of age or less. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2003 Jun. 12 p.

Guideline Availability

Electronic copies: Available from the Cincinnati Children's Hospital Medical Center External Web Site Policy.

Print copies: For information regarding the full-text guideline, print copies, or evidence-based practice support services contact the Cincinnati Children's Hospital Medical Center Health James M. Anderson Center for Health Systems Excellence at EBDMInfo@cchmc.org.

Availability of Companion Documents

The following are available:

Print copies: For information regarding the full-text guideline, print copies, or evidence-based practice support services contact the Cincinnati Children's Hospital Medical Center Health James M. Anderson Center for Health Systems Excellence at EBDMInfo@cchmc.org.

Also, the original guideline document External Web Site Policy contains an appendix with a probability worksheet for finding likelihood ratios for diagnostic tests to detect serious bacterial infection.

Patient Resources

Patient resource information is available from the Cincinnati Children's Hospital Medical Center External Web Site Policy.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This summary was completed by ECRI on September 1, 1998. The information was verified by the guideline developer on December 1, 1998. This summary was updated by ECRI on March 11, 2004. This summary was updated by ECRI Institute on October 3, 2007 following the U.S. Food and Drug Administration (FDA) advisory on Rocephin (ceftriaxone sodium). This summary was updated by ECRI Institute on March 11, 2011.

Copyright Statement

This NGC summary is based on the original full-text guideline, which is subject to the following copyright restrictions:

Copies of this Cincinnati Children's Hospital Medical Center (CCHMC) External Web Site Policy Evidence-Based Clinical Practice Guideline (EBCG) are available online and may be distributed by any organization for the global purpose of improving child health outcomes. Examples of approved uses of CCHMC's EBCG include the following:

  • Copies may be provided to anyone involved in the organization's process for developing and implementing evidence-based care guidelines.
  • Hyperlinks to the CCHMC website may be placed on the organization's website.
  • The EBCG may be adopted or adapted for use within the organization, provided that CCHMC receives appropriate attribution on all written or electronic documents.
  • Copies may be provided to patients and the clinicians who manage their care.

Notification of CCHMC at EBDMInfo@cchmc.org for any EBCG adopted, adapted, implemented or hyperlinked to by a given organization and/or user, is appreciated.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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