From the Guidelines
The initial management of a patient admitted for fever should prioritize assessment, stabilization, and identifying the underlying cause, with empiric antibiotic therapy initiated promptly if bacterial infection is suspected, guided by the likely source of infection, local resistance patterns, and patient factors, as supported by 1. The first step involves obtaining vital signs, including temperature, heart rate, blood pressure, respiratory rate, and oxygen saturation, to evaluate the severity of illness. Collecting blood cultures (two sets from different sites) before starting antibiotics, along with a complete blood count, comprehensive metabolic panel, urinalysis, and chest X-ray, is crucial to identify potential sources of infection. Administering antipyretics such as acetaminophen 650-1000 mg orally every 6 hours (maximum 4000 mg daily) or ibuprofen 400-600 mg orally every 6 hours with food can help reduce fever and improve comfort, as noted in general clinical practice. Ensuring adequate hydration with intravenous fluids is essential if the patient is dehydrated or unable to maintain oral intake. Some key considerations for empiric therapy include:
- The suspected infectious etiology
- Whether the infection is community-, healthcare-, or hospital-onset
- Whether the patient is immunocompromised, as discussed in 1
- The potential for drug-resistant pathogens, which may require broad-spectrum empirical antimicrobial therapy directed against both resistant Gram-positive cocci (including methicillin-resistant S. aureus) and Gram-negative bacilli, as indicated in 1. For example, in suspected community-acquired pneumonia, ceftriaxone 1-2g IV daily plus azithromycin 500mg IV/PO daily might be appropriate, considering local resistance patterns and patient factors. These interventions are crucial because fever represents the body's inflammatory response to various triggers, and while the elevated temperature itself helps fight infection, identifying and treating the underlying cause is essential for effective management and preventing complications, as emphasized in 1.
From the Research
Initial Management of Fever
The initial management of a patient admitted for fever involves a thorough assessment to determine the underlying cause of the fever.
- A complete assessment, including a thorough physical assessment and an evaluation of the history of present illness as well as a detailed review of all the patient's medications, is the first step in this process 2.
- Infection should always be a primary consideration for the cause of a fever, and evaluating each body system can match symptoms with a possible cause for fever 2.
- Noninfectious causes of fever need to be included in the differential diagnostic process 2, 3.
- Adjunctive testing, including C-reactive protein, erythrocyte sedimentation rate, and procalcitonin, has been evaluated in the literature, but these tests do not have the needed sensitivity and specificity to definitively rule in a bacterial cause of fever 3.
- Blood cultures should be obtained in septic shock or if the results will change clinical management 3, 4.
Empiric Antimicrobial Therapy
Empiric antimicrobial therapy may be necessary to reduce mortality in patients with severe sepsis and/or shock.
- Immediate, empiric, broad-spectrum therapy should be given to those with severe sepsis and/or shock, but this approach can drive antimicrobial overuse and resistance and should be accompanied by a commitment to de-escalation and antimicrobial stewardship 4.
- Biomarkers such as procalcitonin can provide decision support for antibiotic use and may identify patients with a low likelihood of infection 4.
- The selection of an appropriate empiric agent can be challenging due to the emerging resistance of target organisms to commonly prescribed antibiotics 5.
- A pharmacodynamic analysis of commonly prescribed antibiotic agents can help determine their probability for achieving microbiologic success against aerobic bacteria associated with secondary peritonitis 5.