1. At our hospital, we will obtain CBC, blood cx., UA.Micro, urine cx., and CSF studies on any infant less than 28 days old. If they have respiratory sxs. or a WBC>20,000 we get a CXR. RSV is variable, though we are already seeing cases of it in August. All of them get admitted and placed on antibiotics. Depending on the physician, we tend to check blood and urine on the 29-60 day old infants, and if the results are abnormal, we get CSF then give Rocephin. If the infant is toxic, they get admitted. Otherwise, we have them follow-up with their PMD (after we've spoken with the physician while the patient is in the ER) or return to our Urgent Care clinic the following day. For the 3-36 month old population, most of our attendings get blood and urine and tend to follow the Boston criteria. However, a few of the ID/PEM double boarded docs will only get urine if the patient has had Prevnar. All the above is for children with no source of infection. The problematic patients for us are the kids who are > 29 days old, not toxic appearing, with abnormal lab values or with a source of infection. If they get admiited, some will chide for being too conservative. On the other hand, if you send these kids home and they get sicker, you don't have a leg to stand upon. If you look at the major Pediatric textbooks (Nelson, Rudolph, and Oski) it seems that they leave the management of this population up to the individual. Personally, I'm somewhat surprised the AAP hasn't derived a practice guideline for the 29-60 day old infant.
2. For the 5 week old with a positive blood culture, most of our physicians would obtain CSF and repeat blood and urine cultures, admit the child, and start prophylactic antibiotics until the culture results returned.
3. A tangential question for the group: What do you do with the >29 day old infant who has a fever, is not toxic in appearance, has no focal source for infection, but has been given oral antibiotics for a "throat infection" by their clinic doctor?
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