What is the approach to managing acute febrile illness?

Management of Acute Febrile Illness

The management of acute febrile illness should follow a structured approach focusing on early identification of the cause, appropriate antimicrobial therapy when indicated, and supportive care to reduce morbidity and mortality.

Initial Assessment and Diagnosis

Vital Signs Monitoring

• Monitor temperature, respiratory rate, pulse, blood pressure, mental status, oxygen saturation at least twice daily 1
• Use Early Warning Score system for efficient monitoring 1
• Look for signs of clinical instability:
  • Temperature >37.8°C
  • Heart rate >100/min
  • Respiratory rate >24/min
  • Systolic blood pressure <90 mmHg
  • Oxygen saturation <90%
  • Inability to maintain oral intake
  • Abnormal mental status 1

Diagnostic Testing

• For respiratory symptoms: Chest X-ray 2
• For severe illness: Blood cultures 2
• For productive cough: Sputum Gram stain and culture 2
• Calculate CURB-65 score if pneumonia is suspected 2

Treatment Approach

Antiviral Therapy

• Initiate antiviral therapy (neuraminidase inhibitors) if:

  1. Acute influenza-like illness
  2. Fever >38°C
  3. Symptoms present for ≤2 days 2

• Recommended regimen:

  • Oseltamivir 75 mg twice daily for 5 days (adults)
  • Reduce dose to 75 mg once daily if creatinine clearance <30 ml/min 2, 3

• Special considerations:

  • Immunocompromised or elderly patients may benefit from treatment even without documented fever 1
  • Treatment may still be beneficial when started after 48 hours in severely ill patients 2

Antibiotic Therapy

For Influenza Without Pneumonia

• Antibiotics not routinely required for previously well adults with acute bronchitis 1
• Consider antibiotics for:
  • Worsening symptoms (recrudescent fever or increasing dyspnoea)
  • High-risk patients with lower respiratory features 1

For Non-Severe Influenza-Related Pneumonia

• Oral therapy preferred: co-amoxiclav or tetracycline 1
• When oral therapy contraindicated: IV co-amoxiclav, or cefuroxime/cefotaxime 1
• Alternative for penicillin-intolerant patients: macrolide (clarithromycin/erythromycin) or respiratory fluoroquinolone 1
• Administer antibiotics within 4 hours of admission 1

For Severe Influenza-Related Pneumonia

• Immediate parenteral antibiotics after diagnosis 1
• Preferred regimen: IV combination of broad-spectrum beta-lactamase stable antibiotic (co-amoxiclav or cephalosporin) plus macrolide 1

Supportive Care

• Acetaminophen: 650-1000 mg every 4-6 hours (maximum 4000 mg/day) for fever and pain 2
• Dextromethorphan: 10-30 mg every 4-8 hours for non-productive cough 2
• Guaifenesin: 200-400 mg every 4 hours for productive cough 2
• Pseudoephedrine: 60 mg every 4-6 hours for nasal congestion (use with caution in patients with hypertension) 2
• Ensure adequate fluid intake and rest 2
• Provide nutritional support in severe or prolonged illness 1
• Assess for cardiac complications and volume depletion 1

Special Considerations

High-Risk Patients

• More vigilant monitoring for:
  • Elderly (≥65 years)
  • Children <2 years
  • Patients with chronic medical conditions
  • Immunocompromised individuals
  • Pregnant women 2

Discharge Criteria

• Patients should be stable for at least 24 hours before discharge
• No more than one of the following unstable clinical factors:
  1. Temperature >37.8°C
  2. Heart rate >100/min
  3. Respiratory rate >24/min
  4. Systolic blood pressure <90 mmHg
  5. Oxygen saturation <90% 1

Follow-up

• Consider follow-up for patients who:
  • Suffered significant complications
  • Had significant worsening of underlying disease 1
• Provide information about illness, medications, and follow-up arrangements at discharge 1

Common Pitfalls to Avoid

• Overtreatment with antimalarial drugs despite negative test results 4
• Overuse of empiric antibiotics for viral etiologies 4
• Failure to consider non-influenza viral causes of febrile illness 4
• Inadequate infection control measures leading to healthcare worker exposure 5
• Delayed antibiotic administration in severe cases (should be within 4 hours) 1