Linee guida
Management della febbre nei primi 60 giorni di vita: fare meno, ma in sicurezza
Fever management in the first 60 days of life: doing less, but safely
Cardace MG, Fiandri G, Baroni L, Bonvicini F, Gargano G, Iughetti L, Predieri B, De Fanti A.
Giugno 2026 - pagg. 375 -379 | DOI: 10.53126/MEB45375
Abstract
Fever in neonates and infants younger than 60 days is one of the most frequent and challenging presentations in pediatric emergency care, because the clinical picture is often nonspecific while the risk of invasive bacterial infections (IBIs), including bacteremia and bacterial meningitis, is substantially higher than in older children (roughly 7-11% of febrile infants, with peak risk in the first two weeks of life). This review summarizes current evidence on the evaluation and management of the febrile newborn and young infant, taking the 2021 American Academy of Pediatrics (AAP) guideline as the main reference and comparing it with European strategies (Step-by-Step, Lab-score) and the NICE guideline. After an initial ill-appearing versus well-appearing triage using the Pediatric Assessment Triangle, the AAP model stratifies well-appearing infants by age (8-21, 22-28, 29-60 days) and integrates clinical assessment with inflammatory biomarkers, particularly procalcitonin, C-reactive protein and absolute neutrophil count, to guide the need for lumbar puncture, empiric parenteral antibiotics and hospitalization. The combined use of biomarkers, especially procalcitonin, has a high negative predictive value for IBIs (a 2025 multicenter study reported 94.2% sensitivity and 99.4% negative predictive value), supporting a more selective approach that safely reduces unnecessary invasive testing and admission in low-risk infants without compromising early detection of serious bacterial disease.
Riassunto
La febbre nel neonato e nel lattante di eta inferiore a 60 giorni e una delle condizioni piu frequenti e complesse dell'urgenza pediatrica, per la clinica spesso aspecifica e per il rischio elevato di infezioni batteriche invasive (IBIs) come sepsi e meningite (circa 7-11% dei lattanti febbrili, massimo nelle prime due settimane). L'articolo sintetizza le evidenze piu recenti sulla gestione, prendendo come riferimento le linee guida AAP 2021 e confrontandole con gli approcci europei (Step-by-Step, Lab-score) e con le NICE. Dopo il triage iniziale ill-appearing vs well-appearing tramite il Triangolo di valutazione pediatrica, il modello AAP stratifica i lattanti well-appearing per fasce d'eta (8-21, 22-28, 29-60 giorni) integrando la valutazione clinica con i biomarcatori infiammatori, in particolare procalcitonina, PCR e conta assoluta dei neutrofili, per modulare l'indicazione a rachicentesi, terapia antibiotica empirica parenterale e ricovero. L'uso combinato dei biomarcatori, soprattutto la procalcitonina, ha un elevato valore predittivo negativo per le IBIs e supporta un approccio piu selettivo che riduce in sicurezza gli interventi non necessari nei soggetti a basso rischio, senza compromettere l'identificazione precoce delle infezioni batteriche gravi.
Classificazione MeSH
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Bibliografia
1. Pantell RH, Roberts KB, Adams WG, et al.; Subcommittee on febrile infants. Clinical Practice Guideline: Evaluation and Management of Well Appearing Febrile Infants 8 to 60 Days Old. Pediatrics 2021;148(2):e2021052228. doi: 10.1542/peds.2021-052228.
2. Nigrovic LE, Mahajan PV, Blumberg SM, et al. Development and Validation of a Prediction Rule to Identify Low Risk Febrile Infants. JAMA Pediatr 2019;173(4):342-351. doi: 10.1001/jamapediatrics.2018.5501.
3. Powell EC, Mahajan PV, Roosevelt G, et al.; Febrile Infant Working Group of the Pediatric Emergency Care Applied Research Network (PECARN). Epidemiology of Bacteremia in Febrile Infants 60 Days of Age and Younger. Ann Emergency Med 2018;71(2): 211-6. doi: 10.1016/j.annemergmed.2017.07.488
4. Greenhow TL, Hung YY, Herz AM, Losada E, Pantell RH. The Changing Epidemiology of Serious Bacterial Infections in Young Infants. Pediatr Infect Dis J 2014;33(6):595-9. doi: 10.1097/INF.0000000000000225.
5. Gomez B, Mintegi S, Bressan S, Da Dalt L, Gervaix A, Lacroix L; European Group for Validation of the Step-by-Step Approach. Validation of the “Step-by-Step” Approach in the Management of Young Febrile Infants. Pediatrics 2016; 138(2):e20154381. doi: 10.1542/peds.2015-4381.
6. Velasco R, Gomez B, Labiano I, et al. Performance of Febrile Infant Algorithms by Duration of Fever. Pediatrics 2024;153(5): e2023064342. doi: 10.1542/peds.2023-064342.
7. National Institute for Health and Care Excellence. Fever in under 5s: assessment and initial management. NICE guideline NG143. Published 07 Nov 2019; last updated 26 Nov 2021. Accessed 2025.
8. Aronson PL, McCulloh RJ, Tieder JS, et al. Consensus Guidelines for the Management of Febrile Infants ≤ 90 Days of Age. Hosp Pediatr 2023;13(4):e144-e158. doi: 10.1542/ hpeds.2022-006918.
9. Miller JM, Binnicker MJ, Campbell S,et al. Guide to Utilization of the Microbiology Laboratory for Diagnosis of Infectious Diseases: 2024 Update by the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM). Clin Infect Dis 2024:ciae104. doi: 10.1093/cid/ciae104.
10. Huber S, Hetzer B, Crazzolara R, Orth-Höller D. The correct blood volume for paediatric blood cultures: a conundrum? Clin Microbiol Infect 2020;26(2):168-73. doi: 10.1016/ j.cmi.2019.10.006.
11. Norman-Bruce H, Umana E, Mills C, McFetridge L, Mitchell H, Waterfield T. Systematic review and meta-analysis assessing the diagnostic test accuracy of procalcitonin in the diagnosis of invasive bacterial infections in febrile infants: a study protocol. BMJ Open 2022;12(8): e062473. doi: 10.1136/bmjopen-2022-062473.
12. Aronson PL, Shabanova V, Shapiro ED, et al.; Febrile Young Infant Research Collaborative. A Prediction Model to Identify Febrile Infants ≤ 60 Days at Low Risk of Invasive Bacterial Infection. Pediatrics 2019;144(1): e20183604. doi: 10.1542/peds.2018-3604.
13. Burstein B, Lirette MP, Beck C, et al. Management of well appearing febrile young infants aged ≤ 90 days. Paediatr Child Health 2024;29(1):50-66. doi: 10.1093/pch/pxad085.
14. Berardi A, Ficarà M, Pietrella E, et al. Stewardship antimicrobica nel neonato e nel piccolo lattante: perché e come praticarla. Medico e Bambino. 2017;7:493-501.
15. Tunkel AR, Hartman BJ, Kaplan SL, et al.
Practice guidelines for the management of
bacterial meningitis. Clin Infect Dis 2004;39 (9):1267-84. doi: 10.1086/425368.
16. Burstein B, Waterfield T, Umana E, Xie J, Kuppermann N. Prediction of Bacteremia and Bacterial Meningitis Among Febrile Infants Aged 28 Days or Younger. JAMA 2026; 335(5):425-33. doi: 10.1001/jama.2025. 21454.
17. Bedetti L, Baraldi A, Leone F, et al. La meningite nel neonato e nel piccolo lattante. Medico e Bambino 2018;37(4):223-8.
18. Milcent K, Faesch S, Gras Le Guen C, et al. Use of Procalcitonin to Reduce Antibiotic Use in Young Febrile Infants. JAMA Pediatr 2016;170(1):62-9. doi: 10.1001/jamapediatrics.2015.3210.
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