Back
to Curriculum Home
Fever
Classify the patient into one of three
categories:
Immunocompetent, nosocomial
Neutropenic
HIV/AIDS
Nosocomial fever
Consider the following reasons for fever:
1. Intravenous catheter
- How long? What type? Any warmth or tenderness at iv site?
- Broviac, central line- suspect MRSA, staph epi.
- Groin- suspect Gram negative organism > s.aureus.
- Peripheral line- s.epi, s. aureus, transient bacteremia.
- Of most concern in patient with prosthetic valve or new heart
murmur.
2. Pneumonia
- Is there a reason for aspiration? (NG tube, post-op, impaired
cough, altered mental status)
- If not, pneumonia is unlikely.
3. Urine
- Fever only results if patient is obstructed or in retention,
regardless of U/A and urine culture.
- Cystitis does not cause fever. Upper tract infection does cause
fever.
- If Foley is freely draining, it is probably not the source.
4. Decubiti
5. Sinusitis
- Consider if NGT in place.
6. DVT/PE
7. Gout/Pseudogout
8. C. difficile:
- Suspect in older patients with diarrhea, receiving antibiotics.
9. Surgical abdomen/diverticulitis
10. Drug fever
- Procainamide, Bactrim, Dilantin, others
11. Tumor fever
12. Resolving hematomas
Plan:
- Review the chart.
- Perform a history and physical exam, tailored to the issues
outlined above.
- Remove central lines.
- Remove peripheral lines.
- Two sets of blood cultures in patients with central lines or
prosthetic valves.
- If patient not toxic, hold off antibiotics until cultures return,
or for resolution. If ill, tailor abx to suspected organisms.
- Antipyretics.
Back to top
Neutropenic patient
- How to define neutropenic fever: 1 temp > 101; 3 temps >100.5
in 24 hrs.
- These patients often do not manifest suppurative signs (infiltrates,
pus).
- Risk of bacteremia highest at ANC of <100.
- Most common differential:
o
Bacteremia from GI
tract, iv.
o
Localized site of
infection.
o
Presumptive infection,
but no microbiological confirmation.
o
No infection.
o
IV, Broviac, porta-cath
o
Gums, teeth, pharynx.
o
Rectal abscess
o
Pulmonary
o
Surgical abdomen
o
C. difficile.
Plan:
Empiric therapy:
o
If no iv catheter,
Ceftazidime.
o
If patient has an
indwelling catheter, remove it and cover s. aureus and s. epi (Vanco/Ceftaz).
o
If
oral/esophageal/perirectal site involved, use Imipenem, or add Flagyl to Ceftaz
for gram negative and anaerobic coverage.
Back to top
HIV/AIDS
- CMV and MAI most common cause of fever in hospitalized AIDS
patient.
- MAI presents as febrile, non-localizable illness.
- A good correlation exists between CD4 count and clinical disease:
o
MTB: typical~350;
atypical presentation<100.
o
PCP: 100-200.
o
MAI: <50.
o
Toxo/Crypto: 50
o
NH Lymphoma: 50
o
CMV
esophagitis/colitis: 25.
Plan:
- Body fluid cultures (blood for MAI, spinal fluid) and imaging as
appropriate
- Antipyretics.
Back to top