From the Guidelines
For a patient presenting with fever, the most appropriate initial step is to assess the risk for complications of severe infection and determine the need for empirical antibiotic therapy, with consideration of the patient's risk factors, such as neutropenia, medical co-morbidities, and severity of symptoms, as recommended by the Infectious Diseases Society of America 1. When evaluating a patient with fever, it is essential to consider the underlying cause and the patient's overall clinical condition. The patient's temperature, hydration status, and presence of other symptoms such as headache, stiff neck, or difficulty breathing should be assessed.
- The patient should be advised to drink fluids regularly to avoid dehydration, with a recommended intake of no more than 2 liters per day 1.
- Antipyretics such as paracetamol may be used to help manage symptoms, but not solely to reduce body temperature, and should be continued only while symptoms are present 1.
- It is crucial to monitor the patient's temperature and seek medical attention if the fever exceeds 103°F (39.4°C), lasts more than three days, or is accompanied by severe symptoms, as these may indicate a more serious underlying condition.
- For patients with COVID-19, paracetamol is preferred over non-steroidal anti-inflammatory drugs (NSAIDs) for managing fever and other symptoms 1.
- In patients with neutropenia, the risk assessment should guide the decision for empirical antibiotic therapy, with high-risk patients requiring hospital admission and intravenous antibiotics, while low-risk patients may be candidates for oral empirical therapy 1.
- Blood cultures should be obtained as soon as possible, with at least two sets of blood cultures drawn from separate sites, and the use of strict aseptic technique to minimize contamination 1.
- The patient's clinical condition and response to treatment should be closely monitored, with adjustments to the treatment plan made as necessary to ensure the best possible outcome.
From the Research
Evaluation of Fever
When a patient presents with fever, it is essential to consider the underlying cause, as fever can be due to various infectious and non-infectious etiologies 2. The evaluation of fever in the emergency department requires a structured approach to recognize the pitfalls in fever evaluation.
Treatment Options
The treatment of fever depends on the underlying cause, and antipyretic drugs such as paracetamol and ibuprofen are commonly used to reduce fever 3, 4. A study found that paracetamol 1,000 mg represents the first choice for the treatment of fever in the emergency department, followed by paracetamol/ibuprofen 500/150 mg 3. However, the use of antipyretics to suppress fever during infection remains a controversial topic, and some studies suggest that fever suppression may interfere with the body's natural defense mechanisms 5, 6.
Key Considerations
When evaluating a patient with fever, it is crucial to consider the following:
- The broad differential diagnosis of fever, including numerous infectious and non-infectious etiologies 2
- The use of adjunctive testing, such as C-reactive protein, erythrocyte sedimentation rate, and procalcitonin, to evaluate the cause of fever 2
- The importance of obtaining blood cultures in septic shock or if the results will change clinical management 2
- The consideration of non-infectious causes of elevated temperature based on the clinical situation 2
- The potential risks and benefits of antipyretic administration, including the possibility of worsening patient outcomes 6
Management Strategies
The management of fever in critically ill medical patients is controversial, and clinical trials are needed to compare fever management strategies 5. A literature review found that the evidence does not currently support routine antipyretic administration, and health professionals should consider patients' comorbidities and symptoms of their underlying illness when administering antipyretics 6. Key management strategies include: