Definitions for the strength of evidence (Class I-III) and strength of recommendations (A-C) are repeated at the end of the Major Recommendations.
Are there useful age cutoffs for different diagnostic and treatment strategies in febrile children?
- Level A recommendations. Infants between 1 and 28 days old with a fever should be presumed to have a serious bacterial infection.
- Level B recommendations. None specified.
- Level C recommendations. None specified.
Does a response to antipyretic medication indicate a lower likelihood of serious bacterial infection in the pediatric patient with a fever?
- Level A recommendations. A response to antipyretic medication does not change the likelihood of a child having serious bacterial infection and should not be used for clinical decision making.
- Level B recommendations. None specified.
- Level C recommendations. None specified.
What are the indications for a chest radiograph during the workup of pediatric fever?
Which children are at risk for urinary tract infection?
- Level A recommendations. Children aged younger than 1 year with fever without a source should be considered at risk for urinary tract infection.
- Level B recommendations. Females aged between 1 and 2 years presenting with fever without source should be considered at risk for having a urinary tract infection.
- Level C recommendations. None specified.
What are the best methods for obtaining urine for urinalysis and culture?
- Level A recommendations. None specified.
- Level B recommendations. Urethral catheterization or suprapubic aspiration are the best methods for diagnosing urinary tract infection.
- Level C recommendations. None specified.
What is the appropriate role of urinalysis, microscopy, and urine cultures?
- Level A recommendations. None specified.
- Level B recommendations. Obtain a urine culture in conjunction with other urine studies when urinary tract infection is suspected in a child aged younger than 2 years because a negative urine dipstick or urinalysis result in a febrile child does not always exclude urinary tract infection.
- Level C recommendations. None specified.
What is the appropriate role of empiric antibiotics among previously healthy, well-appearing children aged 3 to 36 months with fever without a source?
- Level A recommendations. None specified.
- Level B recommendations. Consider empiric antibiotic therapy for previously healthy, well-appearing children, aged 3 to 36 months, with fever without a source with a temperature of 39.0 degrees C or greater (>102.2 degrees F) when in association with a WBC count of 15,000/mm3 or greater if obtained.
- Level C recommendations. In those cases when empiric antibiotics are not prescribed for children who have fever without a source, close follow-up must be ensured.
Definitions:
Strength of Evidence
Strength of evidence Class I – Interventional studies including clinical trials, observational studies including prospective cohort studies, and aggregate studies including meta-analyses of randomized clinical trials only
Strength of evidence Class II – Observational studies including retrospective cohort studies, case-controlled studies, and aggregate studies including other meta-analyses
Strength of evidence Class III – Descriptive cross-sectional studies; observational reports including case series and case reports; and consensus studies including published panel consensus by acknowledged groups of experts
Strength of Recommendation
Level A recommendations. Generally accepted principles for patient management that reflect a high degree of clinical certainty (i.e., based on "strength of evidence Class I" or overwhelming evidence from "strength of evidence Class II" studies that directly address all the issues)
Level B recommendations. Recommendations for patient management that may identify a particular strategy or range of management strategies that reflect moderate clinical certainty (i.e., based on "strength of evidence Class II" studies that directly address the issue, decision analysis that directly addresses the issue, or strong consensus of "strength of evidence Class III" studies)
Level C recommendations. Other strategies for patient management based on preliminary, inconclusive, or conflicting evidence, or, in the absence of any published literature, based on panel consensus
There are certain circumstances in which the recommendations stemming from a body of evidence should not be rated as highly as the individual studies on which they are based. Factors such as heterogeneity of results, uncertainty about effect magnitude and consequences, strength of prior beliefs, and publication bias, among others, might lead to such a downgrading of recommendations.