Fever Management
Fever should be treated primarily for patient comfort rather than for the purpose of reducing temperature, as routine use of antipyretics has not been shown to improve mortality outcomes in febrile patients. 1
Assessment of Fever
- Core body temperature measurement is most accurate using pulmonary artery or esophageal thermistors, but oral or rectal thermometers are acceptable alternatives when central measurement is not available 1
- Tympanic membrane thermometers and temporal artery thermometers show poor agreement with core temperature measurements and should not be relied upon 1
- In critically ill patients, a chest radiograph is recommended as part of the initial workup for new fever (pneumonia being a common cause) 1
Pharmacological Management
General Approach
- Antipyretic medications should not be routinely used for the specific purpose of reducing temperature alone, as this has not been shown to improve mortality outcomes 1
- For patients who value comfort through temperature reduction, antipyretic medications are preferred over non-pharmacological cooling methods 1
- Acetaminophen (paracetamol) is the preferred first-line antipyretic, particularly in children 1
Specific Medications
Acetaminophen (Paracetamol):
Ibuprofen:
Special Populations
Critically Ill Patients
- Fever management in critically ill patients should be individualized based on physiologic reserves 1
- Meta-analysis of 13 RCTs showed fever management reduced body temperature but did not improve 28-day mortality, hospital mortality, or shock reversal 1
Stroke Patients
- In patients with intracerebral hemorrhage (ICH), there is insufficient evidence from RCTs to make strong recommendations on preventive or early fever treatment 1
- Based on circumstantial evidence, early treatment of fever with antipyretics may be considered in ICH patients, but preventive treatment is not recommended outside clinical trials 1
Children with Febrile Seizures
- Physical cooling methods such as fanning, cold bathing, and tepid sponging cause discomfort and are not recommended 1
- Antipyretic treatment should focus on comfort rather than prevention of seizures 1
- Ibuprofen may provide slightly greater fever reduction than acetaminophen in children with history of febrile seizures 4
Combined or Alternating Therapy
- In children with persistent fever, alternating acetaminophen and ibuprofen every 4 hours has shown greater antipyretic effect than monotherapy 2
- Combined therapy (simultaneous administration of acetaminophen and ibuprofen) also provides better fever control than ibuprofen alone 5
- This approach should be reserved for cases where fever causes significant discomfort despite monotherapy 2, 5
Physiological Perspective
- Fever is an evolved defense mechanism that augments immune cell performance and induces stress on pathogens 6
- Observational studies suggest a survival benefit from fever in infections, and randomized trials do not support routine fever reduction 6
- For novel infections like COVID-19, allowing fever to run its course may be beneficial unless evidence suggests otherwise 6
Common Pitfalls to Avoid
- Treating the number on the thermometer rather than the patient's symptoms and comfort 1
- Using unreliable temperature measurement methods (tympanic, temporal) in critical decision-making 1
- Overuse of antipyretics when fever may be beneficial for fighting infection 6
- Failing to identify and treat the underlying cause of fever 1
- Using physical cooling methods that cause discomfort, especially in children 1