What is the appropriate assessment and management for an adult presenting with uvular swelling, chills, and fever?

Management of Uvular Swelling with Fever and Chills in Adults

Immediate Assessment and Airway Evaluation

This presentation requires immediate assessment for airway compromise and prompt initiation of empiric antibiotics targeting Group A Streptococcus and Haemophilus influenzae after obtaining blood cultures. 1, 2

Critical Airway Assessment

• Examine for signs of impending airway obstruction: drooling, difficulty swallowing, muffled voice, stridor, suprasternal retractions, or respiratory distress requiring immediate ENT consultation and potential airway intervention 3, 4, 5
• Position patient upright to optimize airway patency and monitor continuously for deterioration 6, 7
• Prepare for emergent airway management if severe obstruction develops—have equipment ready for intubation or cricothyroidotomy 4, 5

Diagnostic Workup Before Antibiotics

The presence of fever with chills represents a high-risk presentation demanding urgent evaluation:

• Obtain blood cultures immediately (within 30-90 minutes of presentation) before any antibiotic administration, as bacteria are rapidly cleared from the bloodstream 8
• Complete blood count with differential, comprehensive metabolic panel, lactate level to assess for systemic inflammatory response and organ dysfunction 8
• Throat culture or rapid streptococcal antigen test if uvular swelling allows safe visualization without precipitating airway compromise 9
• Lateral neck radiograph or CT imaging only if airway is stable and diagnosis uncertain—imaging should never delay definitive airway management 3, 4

Empiric Antibiotic Therapy

First-Line Treatment

Amoxicillin-clavulanate 875 mg/125 mg orally twice daily for 10 days is the preferred first-line agent, providing coverage against Group A Streptococcus, Haemophilus influenzae, and β-lactamase-producing organisms 1, 2

• This regimen is recommended by the American Academy of Pediatrics and the Infectious Diseases Society of America for bacterial uvulitis 2
• The broader spectrum of amoxicillin-clavulanate is superior to amoxicillin alone due to coverage of β-lactamase-producing H. influenzae and mixed flora 1, 2

Alternative Regimens for Penicillin Allergy

• Second-generation cephalosporins: Cefuroxime-axetil 500 mg orally twice daily for 10 days 1, 2
• Third-generation cephalosporins: Cefpodoxime-proxetil 200 mg orally twice daily for 10 days or cefdinir 300 mg orally twice daily for 10 days 1, 2
• Avoid macrolides (azithromycin, clarithromycin) as they provide inadequate coverage against H. influenzae 2

Indications for Parenteral Antibiotics and Hospitalization

Admit for IV antibiotics and airway monitoring if:

• Signs of severe systemic toxicity, bacteremia, or septic shock (hypotension, altered mental status, organ dysfunction) 2, 8
• Inability to tolerate oral intake due to dysphagia or odynophagia 2
• Evidence of deep space neck infection (retropharyngeal or parapharyngeal abscess) requiring surgical drainage 4
• Hemodynamic instability or oxygen saturation <92% 8

For hospitalized patients requiring IV therapy, use ampicillin-sulbactam 3 g IV every 6 hours or ceftriaxone 1-2 g IV daily 2, 4

Supportive Care

• Antipyretics: Acetaminophen 650-1000 mg orally every 6 hours or ibuprofen 400-600 mg orally every 6 hours for fever control and to reduce severity of rigors 8
• Fluid resuscitation: If hypotensive, initiate 250-500 mL crystalloid boluses with serial lactate measurements 8
• Humidified oxygen if hypoxemic, maintaining oxygen saturation >92% 8, 4
• Corticosteroids: Consider dexamethasone 10 mg IV/IM once to reduce uvular edema, though evidence is extrapolated from croup management 4

Common Pitfalls to Avoid

• Never delay blood cultures until after antibiotic administration—this significantly reduces diagnostic yield 8
• Do not assume stable appearance excludes serious infection—patients ≥50 years with fever and chills have 55% likelihood of serious bacterial infection 8
• Avoid obtaining throat cultures if airway compromise is suspected—instrumentation can precipitate complete obstruction 3, 4
• Do not miss peritonsillar or retropharyngeal abscess—examine for unilateral tonsillar displacement, trismus, or neck swelling requiring urgent ENT evaluation and possible surgical drainage 4
• Recognize Lemierre syndrome (septic thrombophlebitis of internal jugular vein) in young adults with severe pharyngitis/uvulitis and systemic toxicity—requires prolonged IV antibiotics and anticoagulation consideration 9

Monitoring and Follow-Up

• Clinical improvement expected within 24-48 hours of appropriate antibiotic therapy 1, 2
• If no improvement or worsening after 48-72 hours: consider imaging (CT neck with contrast) to exclude abscess formation, alternative pathogens, or non-infectious causes 4
• Complete full 10-day antibiotic course even if symptoms resolve earlier to prevent complications and recurrence 1, 2