Fever
at the bedside
- vitals, random glucose
- confirm → recheck temperature, confirm method (oral / axillary vs tympanic), compare with trend
- definitions
- fever → temperature ≥ 38.0 °C, reliable method
- febrile neutropenia → single oral temp ≥ 38.3 °C, or ≥ 38.0 °C sustained ≥ 1 h, with ANC < 0.5 × 10⁹/L or expected to fall below within 48 h
- significant neutropenia: no rectal temperature, no routine digital rectal exam
- deterioration: hypotension, tachypnea, desaturation, confusion
escalate now if
- hemodynamic instability
- tachypnea or desaturation
- confusion or new AMS
- neutropenic patient with any fever
focused check
- onset, duration, pattern; new vs persistent; measurement method
- identify focal source; sick contacts, food exposure
- chart review
- current antibiotics and infection treatment
- admission length; prior 24 h: surgery, line insertion, new medications, ICU transfer
- MRSA/Pseudomonas risk; immunocompromised status
- renal-adjusted dosing
- system review
- CNS → headache, confusion, seizures, photophobia, neck stiffness
- ENT → purulent ear discharge, sinus tenderness, mastoid pain
- cardiorespiratory → cough, dyspnea, hemoptysis, pleuritic chest pain, new murmur, aspiration risk, ventilator changes
- GI → abdominal pain, bowel changes, N/V
- GU → dysuria, frequency, flank pain; gyne → discharge, pelvic pain
- skin/MSK → cellulitis, ulcers, joint swelling or pain, rash
- devices → pacemaker, PEG, Foley, central line, tracheostomy sites
- examine → oral cavity, skin, joints, cannulas/lines, wounds, pressure areas, surgical sites, chest and heart
- in neutropenia → look for mucositis, subtle skin/line-site changes, perianal symptoms; no routine digital rectal exam
send now
- review infection/inflammation trends: WBC/ANC, CRP ± PCT, previous cultures, viral swabs, relevant imaging
- do not use PCT alone to decide on antibiotics, and do not let it delay treatment
essential
- repeat full vitals; mental status
- capillary refill and peripheral perfusion; urine output
- VBG ± ABG; lactate and trend
- CBC with differential; CRP ± PCT
- RFT/electrolytes; LFT; coagulation profile; glucose
- two sets of blood cultures, before antibiotics if no delay
if indicated
- urinalysis/urine culture
- respiratory viral PCR, sputum/ET aspirate
- wound/ulcer swab if clinically infected
- peripheral + line cultures if line infection suspected
- source-directed imaging: CXR, ultrasound, CT
- urine, stool, sputum, wound, line-tip cultures are source-directed: do not send routinely for every fever
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treat
febrile neutropenia: do not wait
- antipseudomonal β-lactam within 60 min of recognition
- piperacillin-tazobactam 4.5 g IV now over 30 min, then 4.5 g IV every 6 hours, adjusted to renal function
- alternatives (allergy / renal / resistance): cefepime 2 g IV q8h · meropenem 1 g IV q8h · ceftazidime 2 g IV q8h · full options: empiric antibiotics
- no routine vancomycin: add only for hemodynamic instability, suspected line infection, skin / soft-tissue infection, MRSA colonization, pneumonia (severe mucositis alone is not an indication)
- senior / oncology / ID early
suspected sepsis / septic shock
- empiric antibiotics now, within one hour in shock → choose by source
- urgent source control
- hypotension or hypoperfusion → hypotension / septic shock plan
clinically stable
- treat discomfort, not the number: paracetamol 1 g PO q6h (max 4 g/day); oral preferred, IV only when needed
- lower maximum in liver disease, low body weight, frailty, malnutrition
reassess / escalate
- review response and results: vitals trend, pending cultures, CBC / CRP; positive culture → match agent, dose and duration to sensitivities
- adjust: review every IV antibiotic at 48 h; IV → PO early
- not improving → think beyond infection: drug fever, transfusion reaction, VTE / PE, malignancy, inflammatory / autoimmune disease, postoperative inflammation, tissue injury
- escalate: Micro / ID for resistant organisms or no source; senior review if deteriorating; hemodynamic instability → hypotension
before leaving
- document: suspected source, antibiotic started (drug, dose, time), cultures sent
- pending: blood cultures, CBC/CRP trend, source-directed cultures/imaging sent
- hand over: 48 h antibiotic review due, escalation trigger if not improving, who to call
evidence
| source | type |
|---|---|
| Surviving Sepsis Campaign 2026 | international guideline |
| ASCO/IDSA febrile-neutropenia guideline | international guideline |
Verify indication, dose, allergies, interactions, renal/hepatic function and local protocols before prescribing.
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Last clinically reviewed · 17 August 2026 · Last updated · September 2026