Chapter 5: Acute Fever

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5.1 Outline

The clinicians should ensure appropriate antimicrobial treatment in acute fever (fever<7 days). In case of children less than 5 years sign and symptoms should be checked cautiously and according to IMCI management should be done. Patients more than 5 years of age with acute fever should be treated with Paracetamol for Day 1-3. At the same time investigations (CBC with ESR, Urine RME, CXR P/A view, Blood C/S, tests for Dengue/ Malaria if needed) related with the clinical features should be done on Day 4-5. Empirical antibiotics can be prescribed on Day 6-7 with further investigations and modify the antibiotics according to the culture sensitivity report when available.

5.2 Some general principles

5.2.1.   Antibiotic use will need to be classified with respect to type of patient’s status (high- and low-risk according to patient risk stratification mentioned above) and the patient’s place in the treatment pathway (untreated, treated, and posttreatment).

5.2.2.   The choice of medication may vary depending on differences in the case mix of patients, various medicines (of same or different class) listed in the formulary or clinical practice guidelines (such as this guideline).

5.2.3.   Timely use of diagnostic tests or documentation of symptoms supporting the presence of infection would be best. Sample for culture (two sets of blood cultures and other appropriate samples as clinically indicated e.g. normally sterile body fluids, deep pus etc.) should be taken before starting empiric antibiotic treatment if possible.

5.2.4.   Empiric antibiotic treatment for common infections should be limited to conditions where early initiation of antibiotics has been shown to be beneficial, e.g. severe sepsis and septic shock, acute bacterial meningitis, community acquired pneumonia, necrotizing fasciitis, etc.

5.2.5.   Re-assessment of the situation within 48 hours based on the test results and examination of the patient is required. If needed, the medicine's dosage and duration can be adjusted or the antibiotic regimen should be de-escalated (to the narrowest spectrum, least toxic and least expensive antibiotic) based upon patient response and culture and susceptibility reports.

5.3 Diagnostic Investigations

(where facilities are available and according to physician’s discretion)

5.3.1.   Rapid Diagnostic Test (RDT): if needed according to condition (e.g. dengue outbreak, malaria outbreak etc.) following specific guidelines.    

5.3.2.   Complete blood count: Anemia, leucopenia /leukocytosis, elevated hematocrit or thrombocytopenia are all helpful in diagnosis.

5.3.3.   Diagnostic blood cultures (at least two sets) are to be drawn prior to the start of empiric antibiotics.

5.3.4.   Liver enzymes and bilirubin

5.3.5.   Urinalysis – white blood cells, proteinuria and hematuria.

5.3.6.   Chest X-ray (if chest findings are present, to rule out early pneumonia or TB)

5.3.7.   Ultrasonography of abdomen if fever persists to rule out hepatic, renal or intraabdominal sources of infection.

5.3.8.   Within 96 hours of onset of fever, antigen based serological tests are likely to be positive whereas antibody tests are generally positive after at least 57 days of illness.

5.3.9.   Investigations on special situations:

5.3.9.1. Dengue rapid NS1 antigen

5.3.9.2. IgM ELISA for Dengue,  

5.3.9.3. RT PCR or antigen test for SARS-COV-2

5.4 Principles of empiric therapy

5.4.1.   Supportive: Acetaminophen 500 mg every 6 hours round the clock is advisable, accompanied by tepid sponging for fever >103˚F. Replace fluid and electrolytes as required.

5.4.2.   No antibiotics are required for the majority of patients with acute febrile illness without an obvious clinical diagnosis.

5.4.3.   Start antibiotics for a presumed bacterial infection promptly, but adjust the medicine's dosage and duration, switch to a new medicine, or end antibiotic therapy when results do not support or justify the need to continue.

5.4.4.   Reassess the situation within 48 hours based on test results and patient status.

5.4.5.   Corticosteroids are not recommended in the treatment of acute undifferentiated fever.

5.4.6.   In patients with fever and thrombocytopenia, platelet transfusions are not recommended in general (see national clinical management guideline of Dengue).

5.5 Outcome

In most cases of fever, patient may either recover spontaneously or a diagnosis is reached after repeated clinical evaluation and investigations. If no diagnosis is reached in up to 3 weeks, patient is said to be having fever of unknown origin (FUO) and should be managed accordingly.

5.6 Patient education

5.6.1.   Self-medication and over-medication should be avoided

5.6.2.   Avoid injectable paracetamol/NSAIDs

5.6.3.   Antibiotics should be taken only on advice of a physician. 

5.6.4.   Avoid covering the patient with high fever with blanket, etc.

5.6.5.   Plenty of fluids should be taken. Stay in cool environment.
            Washing/sponging of face and limbs should be done repeatedly.