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

Treatment for Fever with Chills

Obtain blood cultures immediately before any antibiotic administration, then start empiric antibiotics within 1 hour if the patient shows hemodynamic instability, signs of septic shock, immunocompromised state, or evidence of organ dysfunction. 1

Immediate Assessment and Risk Stratification

The presence of fever with chills represents a high-risk presentation requiring urgent evaluation. This combination signals potential bacteremia, as chills or rigors indicate a systemic inflammatory response to circulating pathogens. 1 Patients ≥50 years old with fever and chills have a 55% likelihood of serious bacterial infection when combined with other risk factors. 1

Critical red flags requiring immediate action include:

• Hemodynamic instability (systolic BP <90 mmHg, MAP <65 mmHg) 1
• Oxygen saturation <92% 1
• Evidence of organ dysfunction 1
• Altered mental status or confusion 1
• Immunocompromised state (neutropenia, chemotherapy, transplant) 1

Diagnostic Workup: Timing is Critical

Before administering any antibiotics, obtain the following:

• Two sets of blood cultures from separate peripheral sites (20-30 mL per set) 1, 2
• Complete blood count with differential 1
• Comprehensive metabolic panel 1
• Lactate level 1
• Urinalysis and urine culture 1

Blood cultures must be obtained within 30-90 minutes of fever or chills onset, as bacteria are rapidly cleared from the bloodstream and diagnostic yield drops significantly after antibiotic administration. 1, 2 This timing is crucial because fever typically follows bacteremia by this interval. 1

Additional imaging based on clinical presentation:

• Chest radiograph for all patients with fever during ICU stay 3
• CT scan for patients with recent thoracic, abdominal, or pelvic surgery if initial workup is unrevealing 3
• Abdominal ultrasound for patients with abdominal symptoms, abnormal liver function tests, or recent abdominal surgery 3

Empiric Antibiotic Therapy: When to Start

Start empiric antibiotics immediately (within 1 hour) after obtaining cultures if any of the following are present:

• Hemodynamic instability or signs of septic shock 1
• Systemic inflammatory response syndrome 1
• Immunocompromised state with fever 1
• Suspected meningitis (altered mental status, meningismus) 1
• Suspected cholangitis (Charcot's triad: fever, jaundice, right upper quadrant pain) 1
• Oxygen saturation <92% 1
• Evidence of organ dysfunction 1

In patients with cirrhosis and septic shock, mortality increases by 10% for every hour of antibiotic delay. 1 This underscores the critical importance of rapid antibiotic initiation in high-risk patients.

For stable, immunocompetent patients without signs of sepsis or organ dysfunction: It is reasonable to complete the diagnostic workup and observe for 1-2 hours before initiating antibiotics, provided blood cultures have been obtained and close monitoring is in place. 1 However, when in doubt, err on the side of early antibiotic administration after cultures are obtained. 1

Antibiotic Selection Strategy

For neutropenic fever or immunocompromised patients: Use anti-pseudomonal monotherapy (ceftazidime or carbapenem) or combination therapy based on local resistance patterns. 1

For suspected catheter-related bloodstream infection: Obtain one set of blood cultures from the catheter hub and one peripheral set simultaneously before starting antibiotics. 2 Catheter-related infections can manifest as chills and rigors even before temperature elevation, particularly with gram-negative organisms. 2

For travelers from endemic areas: Immediately exclude malaria, dengue fever, enteric fever (typhoid), and rickettsial diseases. 1 Use intravenous ceftriaxone as first-line empiric therapy for suspected enteric fever in travelers from Asia. 1 Initiate doxycycline empirically if clinical suspicion of rickettsial infection is high. 1

Supportive Care and Monitoring

For hypotensive patients:

• Initiate immediate fluid resuscitation with 250-500 mL crystalloid boluses 1
• Implement continuous monitoring: vital signs, pulse oximetry, strict intake and output 1
• Serial lactate measurements to assess tissue perfusion 1

For fever control: Avoid routine use of antipyretic medications for the specific purpose of reducing temperature in critically ill patients. 3 However, for patients who value comfort, use antipyretics over nonpharmacologic methods. 3 Consider prophylactic acetaminophen to reduce severity of rigors and chills. 1

Temperature Monitoring Methods

Central temperature monitoring methods are preferred when accurate measurements are critical, including thermistors for pulmonary artery catheters, bladder catheters, or esophageal balloon thermistors. 3 For patients without these devices, use oral or rectal temperatures over less reliable methods such as axillary or tympanic membrane temperatures. 3

Special Considerations and Common Pitfalls

Avoid these critical errors:

• Delaying blood cultures until after antibiotic administration significantly reduces diagnostic yield 1
• Obtaining blood cultures from central venous catheters increases contamination rates 2
• Assuming "toxic appearance" or high fever reliably predicts bacterial infection 1
• Missing atypical presentations in elderly or cirrhotic patients who may lack fever or localizing symptoms 2

For patients with indwelling vascular catheters placed >48 hours ago: Obtain blood cultures immediately, as catheter-related bloodstream infection is a critical consideration. 2 Examine all vascular access sites for erythema, induration, purulence, or tenderness within 2 cm of exit site. 2

If rising WBC count develops while already on antibiotics: This suggests inadequate antimicrobial coverage, emerging resistance, or secondary infection, and warrants repeat blood cultures obtained immediately before the next antibiotic dose when drug levels are lowest. 2

Disposition Decisions

Immediate hospitalization is mandatory for:

• Oxygen saturation <92% 1
• Evidence of organ dysfunction 1
• Severe thrombocytopenia 1
• Persistent hypotension 1
• Confusion or seizures 1
• Reduced Glasgow Coma Scale 1

Patients with suspected infective endocarditis should be evaluated and managed at a reference center with immediate surgical facilities and a multidisciplinary endocarditis team. 3 Up to 90% of patients with infective endocarditis present with fever, often associated with chills, and up to 25% have embolic complications at diagnosis. 3