What is the best way to treat fever?

Management of Fever

For most patients with fever, antipyretic medications should be used only for symptomatic relief and comfort rather than with the sole aim of reducing body temperature, as routine use of antipyretics does not improve clinical outcomes. 1

Understanding Fever

Fever is a physiological response that typically represents the body's defense mechanism against infection or inflammation. It is characterized by an elevation in body temperature above the normal range, which is generally considered to be around 37°C (98.6°F).

Temperature Measurement

• Preferred methods when accuracy is critical:
  • Central temperature monitoring methods (pulmonary artery catheters, bladder catheters, esophageal thermistors)
  • Oral or rectal temperatures when central monitoring devices aren't available 1
• Avoid less reliable methods:
  • Axillary or tympanic membrane temperatures
  • Temporal artery thermometers
  • Chemical dot thermometers 1

Approach to Managing Fever

General Principles

1. Do not use antipyretics with the sole aim of reducing body temperature 1
2. Treat the underlying cause rather than just the fever
3. Maintain adequate hydration - advise patients to drink fluids regularly (no more than 2 liters per day) 1

Antipyretic Therapy

When to Use Antipyretics:

• For symptomatic relief when patients are uncomfortable 1
• When patients or family members value reducing temperature for comfort 1

Choice of Antipyretics:

• Paracetamol (Acetaminophen) is preferred over NSAIDs for most patients, especially those with COVID-19 or other viral infections 1, 2
  • Discontinue if fever persists more than 3 days or worsens 2
• NSAIDs (e.g., Ibuprofen) may be used for influenza-like illnesses to improve fever and wellbeing 3, 4
  • Use with caution in patients with asthma, as cross-reactivity with aspirin sensitivity can occur 3
  • Monitor for hepatic effects and hematological changes with prolonged use 3

Special Considerations

Critically Ill Patients:

• Avoid routine use of antipyretic medications solely to reduce temperature 1
• If using antipyretics for comfort, pharmacological methods are preferred over physical cooling methods 1
• Perform a chest radiograph for new fever in ICU patients to rule out pneumonia 1
• For post-surgical patients with fever and no obvious source, consider CT imaging of the operative area 1

Pediatric Fever Management:

• Treat fever to promote comfort and prevent dehydration 1
• Avoid physical cooling methods like fanning, cold bathing, and tepid sponging as they cause discomfort 1
• Paracetamol is the preferred antipyretic for children 1
• Ensure adequate fluid intake 1

Fever in Returned Travelers:

• Always exclude malaria first in travelers returning from endemic areas 1
• For suspected enteric fever, blood cultures have highest yield within a week of symptom onset 1
• If clinical condition is unstable with suspected enteric fever, empiric treatment with ceftriaxone is recommended 1

Diagnostic Approach for Persistent Fever

For fever of unknown origin (FUO) that persists despite initial evaluation:

1. Initial workup: Complete blood count, comprehensive metabolic panel, blood cultures, urinalysis, chest radiograph 5

2. Advanced imaging: Consider 18F-fluorodeoxyglucose positron emission tomography/CT if initial tests are unrevealing 1, 5

3. Invasive testing: If noninvasive tests are unrevealing, consider tissue biopsy (liver, lymph node, temporal artery, skin, bone marrow) based on clinical indications 5

4. Avoid empiric antimicrobial therapy for FUO unless the patient is neutropenic, immunocompromised, or critically ill 5

Common Pitfalls to Avoid

• Don't focus solely on reducing temperature - this contributes to "fever phobia" and may mask important diagnostic clues 6
• Avoid empiric antibiotics for fever without a clear source (except in high-risk patients) 5
• Don't rely on less accurate temperature measurement methods when making critical clinical decisions 1
• Avoid NSAIDs in patients with aspirin-sensitive asthma due to risk of severe bronchospasm 3
• Don't assume all fevers require treatment - most febrile episodes are self-limiting and represent appropriate immune responses 4, 6

By focusing on patient comfort and treating the underlying cause rather than just the fever itself, clinicians can provide appropriate care while avoiding unnecessary interventions that may not improve outcomes.