What is the initial workup and treatment for a patient presenting with chills?

Initial Workup and Treatment for a Patient Presenting with Chills

When a patient presents with chills, immediately initiate a comprehensive infectious workup including blood cultures (at least 3 sets), complete blood count with differential, urinalysis with culture, chest x-ray, and skin examination, followed by prompt empirical broad-spectrum antibiotics if there is evidence of systemic toxicity, hemodynamic instability, or high clinical suspicion for serious bacterial infection. 1

Immediate Diagnostic Workup

The presence of chills should raise strong suspicion for bacterial infection, though typical symptoms may be absent in certain populations 1. The following workup should be initiated immediately:

Essential Laboratory Studies

• Blood cultures: Obtain at least 3 sets before initiating any antibiotics to avoid culture-negative infections 1, 2
• Complete blood count with differential: Essential for identifying leukocytosis or leukopenia 1
• Urinalysis and urine culture: To identify urinary tract infection, which accounts for 22% of infections in hospitalized patients 1
• Chest x-ray: To evaluate for pneumonia, which accounts for 19% of infections 1
• Comprehensive metabolic panel: Including electrolytes, renal function, and liver function 3

Additional Studies Based on Clinical Context

• Diagnostic paracentesis: If ascites is present, perform immediately to exclude spontaneous bacterial peritonitis, even in the absence of abdominal symptoms 1
• Skin examination: Thoroughly inspect for cellulitis, abscess, or soft tissue infection 1
• Blood glucose and metabolic assessment: In diabetic patients, obtain plasma glucose, serum ketones, anion gap, and arterial blood gas, as up to 50% of diabetic patients with serious infections may not manifest fever 3

Special Populations Requiring Modified Approach

• Cirrhotic patients: Bacterial infection should be suspected when deterioration occurs, particularly with encephalopathy, acute kidney injury, or jaundice, even without fever 1
• Diabetic patients: Can be normothermic or hypothermic despite serious infection; hypothermia is a poor prognostic sign requiring aggressive intervention 3

Empirical Antibiotic Therapy

Initiate empirical antibiotics immediately after obtaining cultures if any of the following are present: systemic inflammatory response, hemodynamic instability, severe illness (moderate to severe pain or temperature ≥38.3°C), or strong clinical suspicion for serious infection 1, 4.

Timing is Critical

• In patients with cirrhosis in septic shock, mortality increases by 10% for every hour's delay in initiating antibiotics 1
• Empirical therapy should be started as soon as samples for cultures have been collected, particularly in the presence of hemodynamic instability 1

Antibiotic Selection Strategy

For severe community-acquired infections with chills and systemic toxicity:

• Preferred regimen: Intravenous combination of a broad-spectrum beta-lactamase stable antibiotic (co-amoxiclav, cefuroxime, or cefotaxime) together with a macrolide (clarithromycin or erythromycin) 1
• Alternative regimen: Fluoroquinolone with enhanced pneumococcal activity (levofloxacin) combined with a broad-spectrum beta-lactam or macrolide 1

For nosocomial infections or healthcare-associated infections:

• Empirical therapy must be directed at multi-drug-resistant gram-negative bacilli and methicillin-resistant Staphylococcus aureus (MRSA), especially in patients with prolonged hospitalization and recent antibiotic use 4
• Consider MRSA coverage if the patient has been hospitalized within the last few months 1

For spontaneous bacterial peritonitis in cirrhotic patients:

• Initiate empirical antibiotics immediately after diagnostic paracentesis if absolute neutrophil count >250/mm³ 1

Monitoring and Reassessment

Initial Monitoring (First 24-48 Hours)

• Vital signs: Monitor every 4 hours, or every 2 hours if hemodynamically unstable 1
• Temperature trends: Document response to antipyretics and antibiotics 1
• Fluid status: Strict intake and output monitoring every 8 hours 1
• Mental status: Neurologic assessment every 8 hours, particularly in cirrhotic or diabetic patients 1, 3

Reassessment for Treatment Failure

If fever and chills persist after 3-5 days of treatment, consider 2:

• Nonbacterial infection (viral, fungal, parasitic)
• Resistant bacterial infection requiring antibiotic modification
• Emergence of secondary infection
• Inadequate antibiotic levels or drug fever
• Infection at an avascular site (abscess, empyema)

Transition to Oral Therapy

• Transfer to oral antibiotics when clinical improvement occurs and temperature has been normal for 24 hours, provided there is no contraindication to oral route 1

Common Pitfalls to Avoid

• Do not delay antibiotics waiting for culture results if the patient has systemic toxicity, hemodynamic instability, or high clinical suspicion for serious infection 1, 4
• Do not initiate antibiotics before obtaining blood cultures in stable patients, as this can lead to culture-negative infections and complicate diagnosis 1, 2
• Do not rely on fever presence or absence to gauge infection severity in diabetics or cirrhotic patients—look for metabolic decompensation and organ dysfunction 1, 3
• Do not overlook spontaneous bacterial peritonitis in cirrhotic patients with ascites presenting with chills, even without abdominal symptoms 1
• Do not underestimate infection severity in patients with multiple comorbidities or immunosuppression 4
• Do not use narrow-spectrum antibiotics empirically in seriously ill patients with chills and suspected sepsis—broad-spectrum coverage is necessary until organism identification and susceptibility testing are available 4