Management of Fever in Nephrotic Syndrome
Promptly initiate appropriate therapeutic antibiotics in patients with proven or suspected acute bacterial infection, as infections are a major cause of morbidity and mortality in nephrotic syndrome. 1
Immediate Assessment and Action
When fever develops in a patient with nephrotic syndrome, immediate evaluation is critical:
Obtain blood cultures and start empirical broad-spectrum antibiotics immediately without waiting for culture results, as these patients are at high risk for life-threatening bacterial infections, particularly from encapsulated organisms (pneumococci, meningococci, Haemophilus influenzae). 1
Assess for clinical indicators of sepsis including tachycardia, hypotension, prolonged capillary refill time, and altered mental status at every encounter. 1
Monitor complete blood count, inflammatory markers, and renal function to guide antibiotic selection and assess for complications. 1
Antibiotic Selection
The choice of empirical antibiotics should cover the most common pathogens:
Use broad-spectrum coverage targeting encapsulated bacteria as first-line therapy, as patients with nephrotic syndrome lose IgG and complement opsonins in urine, making them particularly susceptible to these organisms. 1
Consider cefepime or similar fourth-generation cephalosporins for empirical coverage, as they provide excellent activity against both Gram-positive and Gram-negative organisms and are stable against many beta-lactamases. 2
Adjust antibiotics based on culture results and clinical response within 48-72 hours of initiation. 1
Important Caveat: Prophylactic Antibiotics Are NOT Recommended
Do not use prophylactic antibiotics routinely, as multiple studies demonstrate they are not associated with significant reduction in sepsis rates in nephrotic syndrome patients. 1, 3
Specific Infection Scenarios
If Congenital Syphilis is Suspected:
- Administer penicillin G (50,000 U/kg intravenously every 12 hours if ≤1 week old, every 8 hours if >1 week old, every 6 hours if >1 month old) or benzathine penicillin G (50,000 U/kg intramuscularly every 24 hours for 10-15 days). 1
If CMV Infection is Confirmed:
- Treat with ganciclovir (6 mg/kg every 12 hours for 15-21 days) followed by valganciclovir (15 mg/kg every 12 hours for 6 weeks). 1
- Monitor ganciclovir levels if available, as standard dosing frequently fails to achieve target AUC of 40-50 μg*h/ml in newborns. 1
If Varicella-Zoster Virus (VZV) Infection Occurs:
- Administer intravenous high-dose acyclovir for 7-10 days for active VZV infection. 1
Adjunctive Measures During Febrile Episodes
Consider IVIG infusion in combination with parenteral antibiotics if plasma IgG levels are low and the patient has severe or recurrent infections, as IVIG may reduce nosocomial infections (RR 0.47,95% CI 0.31-0.73). 1, 3
Maintain adequate intravascular volume during febrile illness, as fever increases insensible losses and patients may develop hypovolemia; use albumin infusions only if clinical indicators of hypovolemia are present (oliguria, prolonged capillary refill, tachycardia, hypotension). 4
Monitor for thrombotic complications closely during acute illness, as fever and infection further increase the already elevated thrombotic risk in nephrotic syndrome. 1
Monitoring During and After Fever
Assess volume status, blood pressure, and renal function daily during acute febrile illness. 4
Watch for acute kidney injury, which can complicate both the infection and its treatment in nephrotic syndrome patients. 5
Screen for secondary infections if fever persists beyond 48-72 hours of appropriate antibiotic therapy. 1
Critical Pitfall to Avoid
Never delay antibiotic initiation while awaiting diagnostic workup, as infections are the primary cause of death in nephrotic syndrome patients and rapid progression to sepsis can occur. 1 The immunocompromised state from urinary immunoglobulin losses makes these patients uniquely vulnerable to fulminant bacterial infections.