Optimal management of febrile children < 3 years without infectious focus is controversial

Management variables: age, temperature at presentation, and low vs high risk for serious bacterial infection

Fever: rectal temp > 38°C (100.4°F)

Fever without source (FWS): acute febrile illness, etiology not apparent

Serious bacterial infection (SBI): meningitis, sepsis, bone and joint infections, urinary tract infections, pneumonia, and enteritis

Occult bacteremia (OB): pathogenic bacteria in the blood without appearance of toxicity

Toxic: clinical picture consistent with sepsis syndrome (lethargy with signs of poor perfusion, marked hypoventilation or hyperventilation, or cyanosis)

Lethargy: level of unconsciousness characterized by poor or absent eye contact, or failure of a child to recognize parents or to interact with persons or objects in the environment

All clinically septic or toxic patients should undergo a full septic workup, admission, and initial empiric intravenous antibiotics according to age

The remainder of the guidelines will pertain to those infants and children who appear nontoxic and without a focus of infection at presentation

High risk for SBI, incidence of SBI 12-13%

Cannot use same risk stratification protocols used in infants 1-3 months in < 1 month age group: 2-3% risk of missing SBI

Risk stratification criteria have been developed to identify nontoxic patients at lower risk of SBI

Over the last 10-15 years, different criteria have been proposed by various authors to identify infants at low risk for SBI (< 1%)

Two examples include the Rochester and Baker criteria

Criteria may be difficult to compare at different age groups; some studies included lumbar puncture and/or stool examination