Fever

1.     Defined as T > 38.5C and in neutropenic, organ transplant, and dialysis patients, T > 38.0C.

2.     Your differential diagnosis is fairly broad.

  • Infection (lung, heart, brain, urine, sinuses, prostate, abdomen, skin, lines)
  • Inflammation (collagen vascular disease, neoplastic disease, mucositis)
  • Drug fever (beta lactam antibiotics, amphotericin, and chemotherapy are frequent offenders)
  • Pulmonary embolism or DVT
  • Neurologic (spinal cord injury, hypothalamic injury, intracranial hemorrhage, seizures, subdural hematoma)
  • Endocrine (adrenal insufficiency, thyrotoxicosis)
  • Miscellaneous (aspiration, blood product reaction, atelectasis, hematoma, pancreatitis, MI)

3.     After day 3 of hospitalization, the incidence of nosocomial infection and drug-induced fever goes up substantially.  Note that nosocomial meningitis is exceedingly rare in the absence of head injury or neurosurgery.

  • Common nosocomial infections: UTI (especially in patients with Foley catheters), pneumonia, vascular catheter related infections, wound infections, antibiotic-associated colitis
  • Less common: decubitus ulcers, acalculous cholecystitis, nosocomial sinusitis

4.     As stated above, drug-induced fevers are quite common in hospitalized patients.  Clues are relative bradycardia, presence of a rash, eosinophilia, and the patient being subjectively unaware of fever despite high temperatures.  Always look at the medication record!

5.     Work-up: first determine whether the patient is stable or unstable

  • Look at other vital signs and examine the patient
  • Blood pressure is the most important vital sign to monitor frequently for development of hypotension and septic shock.  Also worrisome is tachypnea (often an early sign of sepsis).
  • If unstable, you may want to call for backup and arrange for an ICU transfer.
  • Take a focused H&P.  Remember drug allergies!  Determine whether additional studies to rule out the above diagnoses are indicated (e.g. CXR & U/A are often indicated).
  • Determine whether blood cultures have been drawn within 48 hours. If so, there is generally no need to draw additional cultures.

6.     Treatment:

  • In most cases, it is prudent to withold empiric antibiotics unless obvious sign of infection (e.g. new infiltrate on CXR).  An exception to this rule is patient who is hemodynamically unstable or with other signs of sepsis or septic shock.
  • Most bone marrow transplant units have an antibiotic algorithm to follow.  Consult your local hospital?s pharmacy for more information.
  • Antipyretics:
    • Tylenol 650 mg PO or for suspected neoplastic fevers, naproxen 375 mg PO q12h.
    • Remember that fever can augment the host defense system and routine antipyretics can mask the disease process and may delay diagnostic evaluation or changes in antibiotics.  Therefore, unless there is a good reason for treating with antipyretics such as extreme pt discomfort, AMS due to fever (common in the elderly), or cardiac disease vulnerable to the hypermetabolic state, consider resisting the temptation to lower the temperature.