How should a two‑day fever with chills be managed?

Management of Two-Day Fever with Chills

For a patient presenting with two days of fever and chills, immediately obtain blood cultures and complete diagnostic workup before initiating empiric antibiotics, which should be started within 1 hour if any signs of hemodynamic instability, sepsis, organ dysfunction, or immunocompromise are present. 1

Immediate Risk Stratification

The presence of fever with chills is a high-risk presentation requiring urgent evaluation. This combination indicates a 55% likelihood of serious bacterial infection in patients ≥50 years old when combined with other risk factors 1. Assess immediately for:

• Hemodynamic instability (systolic BP <90 mmHg, heart rate >100/min) 1, 2
• Respiratory compromise (oxygen saturation <92%, respiratory rate >24/min) 1, 2
• Organ dysfunction signs (altered mental status, oliguria, elevated lactate) 1
• Immunocompromised state (neutropenia, chemotherapy, transplant, cirrhosis) 1

Diagnostic Workup (Before Antibiotics)

Before any antibiotic administration, obtain the following within 30-90 minutes of presentation 1:

• Blood cultures (two sets from separate sites—never from central lines due to contamination risk) 1
• Complete blood count with differential (looking for leukocytosis, left shift with band forms) 1
• Comprehensive metabolic panel (assess for acute kidney injury, hypoalbuminemia) 1
• Lactate level 1
• Urinalysis and urine culture 1
• Chest radiograph (pneumonia is the most common cause of fever in this setting) 3

Critical timing consideration: Blood cultures must be obtained as soon as possible after fever onset, ideally within 30-90 minutes, as bacteria are rapidly cleared from the bloodstream 1. Delaying cultures until after antibiotics significantly reduces diagnostic yield 1.

When to Start Empiric Antibiotics Immediately

Initiate empiric antibiotics within 1 hour after obtaining cultures if ANY of the following are present 1:

• Hemodynamic instability or signs of septic shock 1
• Systemic inflammatory response with organ dysfunction 1
• Immunocompromised state (neutropenia, chemotherapy, transplant) 1
• Suspected meningitis (altered mental status, meningismus) 1
• Suspected cholangitis (fever, jaundice, right upper quadrant pain) 1
• Cirrhosis with septic shock (mortality increases 10% per hour of antibiotic delay) 1

When Antibiotics Can Be Deferred

In 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.

Supportive Care Measures

Fluid Resuscitation

For hypotensive patients, initiate immediate fluid resuscitation with 250-500 mL crystalloid boluses 1. Implement strict monitoring including vital signs at least twice daily, pulse oximetry, intake/output monitoring, and serial lactate measurements 1, 2.

Fever Management

Avoid routine use of antipyretics solely for temperature reduction 3. The evidence shows that antipyretic medications do not improve mortality in critically ill patients 3. However, antipyretics are appropriate when:

• Patient values comfort and symptomatic relief from fever 3
• Prophylactic acetaminophen to reduce severity of rigors and chills 1

Paracetamol 1,000 mg represents the first-choice antipyretic, with paracetamol/ibuprofen combination (500/150 mg) being more effective in bacterial fever within the first hour 4.

Oxygen Support

Provide supplemental oxygen if oxygen saturation falls below 90% 2.

Special Considerations

Travel History

If recent travel to endemic areas, immediately exclude malaria, dengue fever, enteric fever, and rickettsial diseases 1. Initiate empiric treatment for suspected life-threatening tropical infections with clinical instability while awaiting confirmatory testing 1.

Elderly Patients

Be aware that elderly or cirrhotic patients may lack fever or localizing symptoms despite serious infection 1. Maintain high clinical suspicion even with atypical presentations.

Red Flags Requiring Immediate Hospitalization

The following mandate immediate hospital admission 1, 2:

• Oxygen saturation <92%
• Evidence of organ dysfunction
• Severe thrombocytopenia
• Persistent hypotension
• Confusion or altered mental status
• Seizures or reduced Glasgow Coma Scale
• Two or more unstable clinical factors (temperature >37.8°C, heart rate >100/min, respiratory rate >24/min, systolic BP <90 mmHg) 2

Common Pitfalls to Avoid

• Never delay blood cultures until after antibiotic administration—this significantly reduces diagnostic yield 1
• Do not assume "toxic appearance" or high fever predicts bacterial infection—these are unreliable indicators 1
• Avoid obtaining blood cultures from central venous catheters—this increases contamination rates 1
• Do not miss atypical presentations in elderly or cirrhotic patients who may lack fever or localizing symptoms 1