What is the best course of treatment for a patient in their early 70s with a history of fever and vomiting since Wednesday?

Management of Fever and Vomiting in a Patient in Their Early 70s

For a patient in their early 70s with intermittent fever and vomiting since Wednesday, immediately assess for dehydration and signs of sepsis, initiate oral rehydration therapy, obtain blood and urine cultures, and start empiric broad-spectrum antibiotics if the patient shows signs of systemic illness (hypotension, altered mental status, persistent high fever >38.5°C, or appears toxic). 1, 2

Immediate Assessment Priorities

Evaluate for Life-Threatening Conditions

• Check vital signs immediately: Look for hypotension (systolic BP <90 mmHg), tachycardia, fever >38.5°C, altered mental status, or signs of shock 2
• Assess hydration status: Document thirst, tachycardia, orthostatic changes, decreased urine output, lethargy, and decreased skin turgor 1
• Determine if patient appears "toxic": In elderly patients, this includes lethargy, poor perfusion, confusion, or inability to maintain oral intake 3, 2

Special Considerations for Elderly Patients

• Fever definition differs in elderly: a single oral temperature ≥37.8°C (100°F), repeated temperatures ≥37.2°C (99°F), or increase ≥1.1°C over baseline 3, 2
• Presentation may be atypical with fewer classic symptoms and more functional decline 2
• Higher risk for serious infections including pneumonia, urinary tract infection, intra-abdominal infections, and sepsis 3

Initial Management Steps

1. Rehydration (Highest Priority)

• Start oral rehydration solution immediately if patient can tolerate oral intake: goal of 8-10 large glasses of clear fluids per day 1
• If unable to maintain oral hydration or signs of severe dehydration present: initiate IV fluid resuscitation 2

2. Diagnostic Workup

Obtain immediately:

• Blood cultures (before antibiotics if possible) 1, 4
• Urinalysis and urine culture 3, 1
• Complete blood count, comprehensive metabolic panel, lactate 2
• Chest radiography if respiratory symptoms present 2

3. Empiric Antibiotic Therapy - Decision Algorithm

START ANTIBIOTICS IMMEDIATELY IF:

• Fever >38.5°C with signs of sepsis (hypotension, altered mental status, tachycardia) 3, 1, 2
• Patient appears toxic or has severe dehydration 3, 2
• Persistent high fever despite supportive care 1
• Bloody diarrhea with fever 3, 1

Empiric antibiotic choices for elderly patients with suspected sepsis:

• Ceftriaxone 1-2g IV daily for broad coverage of community-acquired infections 3, 4
• Alternative: Azithromycin 500mg daily if fluoroquinolone resistance suspected or for atypical coverage 3, 4
• Avoid fluoroquinolones empirically if travel to Asia or high local resistance rates 3, 4

4. Symptomatic Management

For Vomiting:

• Ondansetron 4-8mg IV/oral for persistent vomiting preventing oral intake 5
• Avoid loperamide if fever ≥38.5°C due to risk of toxic megacolon with invasive bacterial infection 1

For Fever:

• Acetaminophen as needed for comfort 3

Red Flags Requiring Hospitalization

Admit immediately if any of the following present: 1, 2

• Severe dehydration (hypotension, oliguria, altered mental status)
• Persistent high fever despite treatment
• Inability to maintain oral hydration
• Signs of systemic illness or sepsis
• Bloody vomiting or stools
• Severe abdominal pain suggesting intra-abdominal infection 3

Common Pitfalls to Avoid

• Do not dismiss atypical presentations: Elderly patients may have serious infections without classic fever or may present primarily with functional decline 3, 2
• Do not delay antibiotics in sepsis: If patient appears toxic or has signs of sepsis, start antibiotics immediately after obtaining cultures 2
• Do not use antidiarrheals with high fever: Loperamide is contraindicated when fever ≥38.5°C suggests invasive bacterial infection 1
• Do not assume viral gastroenteritis: In elderly patients, consider urinary tract infection, pneumonia, cholecystitis, diverticulitis, and appendicitis 3

Monitoring and Follow-Up

• If managed outpatient: Patient must be able to maintain oral hydration and have close follow-up within 24-48 hours 1
• Document stool frequency and characteristics if diarrhea present 1
• Expect clinical improvement within 5-7 days with appropriate therapy 1
• Re-evaluate immediately if symptoms worsen, new symptoms develop, or no improvement within 48 hours 1