Infant
Appearance and history
Signs of an ill-appearing infant
Tachypnea, apnea or grunting; pale, gray, cyanotic or mottled color, poor perfusion; poor tone, limp, weak cry; bulging fontanelle; irritability, inconsolability, decreased alertness, listlessness or lethargy.
HSV risk factors
Maternal vesicles and/or fever within 48 hours before or after delivery; postnatal oral HSV exposure; vesicles or mucous membrane ulcers; abnormal mental status or seizure; hypothermia; CSF pleocytosis or RBCs; leukopenia; thrombocytopenia.
Work-up
Enter the age to see the work-up.
Results
Procalcitonin available?Urinalysis (catheter specimen)
CSF (if LP done)
Plan
Enter the age and appearance to start.
After admission
Discharge criteria (negative cultures)
Well-appearing and feeding well; blood, urine and CSF cultures (if obtained) negative for at least 24–36 hours, per local lab reporting (confirm with the lab if the record isn't updated); HSV studies negative if sent; PCP notified with follow-up within 72 hours.
Low-risk 22–28 days: admit and observe. If the baby becomes ill-appearing or the blood culture turns positive, do an LP and start antibiotics. If only the urine culture turns positive with a negative UA and the baby is well, an LP can be deferred and empiric antibiotics started. Inflammatory markers can be normal early: if still febrile and first seen less than 6 hours after fever onset, consider repeating them.
Any positive culture or HSV PCR
HSV PCR positive: consult ID. Positive cultures: target antibiotics to speciation and sensitivities; repeat the blood culture (before changing antibiotics) for bacteremia; ID consult and meningitic dosing for CSF growth; renal and bladder ultrasound (consider urology) for UTI. If no LP was done, perform one promptly (before antibiotics if not started). After failed attempts, consider point-of-care ultrasound for hematoma or referral to IR.
LP indicated but no CSF obtained
Inpatient LP is preferred for most. Weigh age, inflammatory markers (22–56 days) and initial appearance; use shared decision-making; consider ID consultation.
Other tests
CSF: Gram stain and culture, protein, glucose, cell count and differential, and save a specimen. CSF enterovirus PCR if pleocytosis (consider blood enterovirus PCR too). Stool bacterial panel or culture if mucus or blood in the stool; consider a GI virus panel. Chest X-ray as indicated. ANC under 1,000 should be interpreted in clinical context.