Today, I review, link to, and excerpt from Emergency Medicine Cases‘ “Ep 212 PECARN Febrile Young Infant Prediction Tool: When To Safely Forgo LP and Empiric Antibiotics“.*
*Cite this podcast as: Helman, A. Burstein, B. Kuppermann, N. Episode 212 PECARN Febrile Young Infant Prediction Tool: When To Safely Forgo LP and Empiric Antibiotics. Emergency Medicine Cases. January, 2026. https://emergencymedicinecases.com/febrile-infant-pecarn-prediction-tool. Accessed February 2, 2026
All that follows is from the above resource.
If you’ve been practicing EM for more than a decade, your approach to the febrile young infant has (appropriately) evolved. For years, the default was LP + empiric antibiotics + admission for almost everyone. That approach prevented missing meningitis, but at the cost of a lot of harm: invasive testing, unnecessary antibiotics, and hospitalization-related complications. The modern approach is a paradigm shift toward risk stratification, biomarkers, and shared decision-making, while still respecting one immutable truth: Missing neonatal bacterial meningitis can be catastrophic. This episode revisits the framework from a prior EM Cases episode and updates it with a landmark study that directly informs how far we can safely go—especially in the 0–28 day group, with the father of multiple well-known PECARN rules Dr. Nathan Kuppermann and lead author Dr. Brett Burstein…
Click this link to play the podcast. Download (Duration: 47:36 — 43.6MB)
Febrile young infants and the paradigm shift in workup and management
Historically, most febrile young infants were managed with a one-size-fits-all approach that included a routine lumbar puncture, empiric antibiotics, and hospital admission. While this strategy reduced the risk of missing bacterial meningitis, it also caused significant harm through invasive testing, unnecessary antibiotic exposure, and hospitalization-related complications. Management has shifted toward a more nuanced approach that emphasizes careful risk stratification, the use of biomarkers, and shared decision-making with families—while still respecting the reality that missed neonatal meningitis may portend a catastrophic outcome.
This evolution is reflected in a shift in terminology. The older term serious bacterial infection (SBI) grouped together urinary tract infection, bacteremia, and bacterial meningitis. The latest frameworks instead focus on invasive bacterial infection (IBI), as outlined in the American Academy of Pediatrics clinical practice guidelines, which is defined strictly as bacteremia and bacterial meningitis, excluding UTIs. This distinction matters. UTIs are common, generally easier to identify, and urinalysis performs well as a screening test. In contrast, the true “can’t-miss” diagnosis is bacterial meningitis. Even within IBI, meningitis and bacteremia are not equivalent in clinical consequence—meningitis generally carries more morbidity and mortality than bacteremia—and recent studies and decision tools increasingly evaluate meningitis risk separately rather than treating all infections as a single composite outcome.
