Pediatric Hospital Medicine – SHM, AAP, APA

View all recommendations from this society

January 11, 2021

Do not continue hospitalization in well-appearing febrile infants once bacterial cultures (i.e. blood, cerebrospinal, and/or urine) have been confirmed negative for 24–36 hours, if adequate outpatient follow-up can be assured.

Routinely continuing hospitalization beyond 24–36 hours of confirmed negative bacterial cultures for well-appearing infants admitted for concern of serious bacterial infection does not improve clinical outcomes. Blood culture yield is highest in the first 12–36 hours after incubation with multiple studies demonstrating >90% of pathogen cultures being positive by 24 hours. If adequate outpatient follow-up can be assured, discharging well-appearing febrile infants at 24–36 hours if cultures are confirmed to be negative will decrease length of stay, antibiotic exposure, and iatrogenic complications.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

How The List Was Created

A diverse committee with representatives from the Society of Hospital Medicine’s Pediatrics Special Interest Group, the American Academy of Pediatrics’ Section on Hospital Medicine and the Academic Pediatric Association’s Hospital Medicine Special Interest Group solicited a list of recommendations with specified criteria from colleagues and the various society listservs. Through an iterative process, recommendations were formatted, merged, and presented with an evidence review of publications from the past 10 years supporting each recommendation. From over 100 initial recommendations and through 2 rounds of a modified Delphi process, the highest scoring recommendations were chosen to represent the Pediatric Hospital Medicine Choosing Wisely list. The list was endorsed by the Boards of the Society of Hospital Medicine and the Academic Pediatric Association and peer reviewed by various AAP specialty groups and endorsed by the American Academy of Pediatrics’ Executive Committee.


Vachani JG, McNeal-Trice K, Wallace SS. Current Evidence on the Evaluation and Management of Fever Without a Source in Infants Aged 0-90 Days: A Review. Rev Recent Clin Trials. 2017;12(4):240-245.
Biondi EA, Mischler M, Jerardi KE, e al; Pediatric Research in Inpatient Settings (PRIS) Network. Blood culture time to positivity in febrile infants with bactremia. JAMA Pediatr. 2014 Sep;168(9):844-9.
Fielding-Singh V, Hong DK, Harris SJ, et al; Ruling out bacteremia and bacterial meningitis in infants less than one month of age: is 48 hours of hospitalization necessary? Hosp Pediatr. 2013;3(4):355–61.
Tara L. Greenhow, Yun-Yi Hung, Arnd M. Herz Changing Epidemiology of Bacteremia in Infants Aged 1 Week to 3 Months Pediatrics Mar 2012, 129 (3) e590-e596; DOI: 10.1542/peds.2011-1546
Mahajan, P., et al., Risk of Bacterial Coinfections in Febrile Infants 60 Days Old and Younger with Documented Viral Infections. J Pediatr, 2018. 203: p. 86-91 e2.
Lefebvre CE, Renaud C, Chartrand C. Time to positivity of blood cultures in infants 0 to 90 days old presenting to the emergency department: is 36 hours enough? J Pediatric Infect Dis Soc. 2017; 6:28–32.