Rochester Criteria for Febrile Infants

• Herpes simplex virus (HSV) risk factors should be carefully assessed, including: maternal history of HSV infection or primary lesions at delivery, household contacts with lesions, vesicular rash, presentation with seizures, or pleocytosis on cerebrospinal fluid (CSF) testing.
• Positive viral testing (e.g. RSV, influenza) reduces serious bacterial infection (SBI) likelihood by ~50%, but the risk of concurrent SBI is NOT zero (Greenhow 2014, Krief 2009).
• The gold standard for urine culture is a sample obtained via straight catheterization. “Bag” urine introduces risk of specimen contamination with skin flora.
• Obtain blood, urine, and CSF samples BEFORE starting antibiotics, if possible.
• Differential diagnosis of ill-appearing infants <60 days of age should also include the following: congenital heart disease, metabolic disease (e.g. galactosemia), congenital adrenal hyperplasia with adrenal crisis, and non-accidental trauma.

If LOW risk (in the derivation study, SBI occurred in 1% of low risk infants):

• Limited testing, including complete blood count, blood culture, urinalysis, and urine culture, is recommended.
• These infants generally do not require antibiotics.
• Generally safe to be discharged home, given no social concerns or question of ability to follow up with their primary care provider (PCP).

If NOT low risk (in the study, SBI occurred in 12.3% of infants not at low risk):

• Further testing is required, including complete blood count, blood culture, urinalysis, urine culture, and cerebrospinal fluid (CSF) testing.
• Empiric broad spectrum antibiotic coverage is indicated.
• Admission is recommended, pending negative cultures at 24-36 hours.