Fever

at the bedside

full vitals, capillary glucose
confirm → recheck temperature, same method, compare with trend
definitions
- fever → temperature ≥ 38.0 °C
- 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
neutropenic → no rectal temperature, no rectal exam

escalate now if

onset, duration, pattern; new or persistent
chart → current antibiotics, previous cultures, day of stay, last 24 h (surgery, lines, new drugs, transfusion), MRSA / Pseudomonas risk, immunosuppression
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 → mouth, skin, joints, cannulas and lines, wounds, pressure areas, surgical sites, chest and heart
neutropenic → mucositis, subtle skin or line-site changes, perianal symptoms

two sets of blood cultures before antibiotics, if this does not delay them
CBC with differential, CRP; RFT, LFT, coagulation, glucose
VBG with lactate if unwell
by source only → urinalysis and culture, sputum or viral PCR, wound swab if infected, peripheral plus line cultures if line infection suspected, CXR or other imaging
PCT does not decide antibiotics on its own and must not delay them

febrile neutropenia: do not wait

antipseudomonal β-lactam within 60 min
- piperacillin-tazobactam 4.5 g IV over 30 min now, then 4.5 g IV every 6 hours, renally adjusted
- allergy, renal or resistance → cefepime 2 g IV q8h · meropenem 1 g IV q8h · ceftazidime 2 g IV q8h → empiric antibiotics
add vancomycin only for hemodynamic instability, suspected line infection, skin or soft-tissue infection, MRSA colonisation or pneumonia
senior, oncology and ID early

suspected sepsis / septic shock

sepsis = infection with new organ dysfunction (SOFA · MDCalc ↗︎ rise ≥ 2); RR ≥ 22, confusion or SBP ≤ 100 (qSOFA) flag high risk but do not rule sepsis out
cultures, then antibiotics within 1 h; source unknown → piperacillin-tazobactam 4.5 g IV now, then 4.5 g IV every 6 hours, or cefepime 2 g IV q8h; MRSA risk (prior MRSA, recent IV antibiotics, line, dialysis, chronic wound) → add vancomycin 25 mg/kg IV load
tailor to the source once known → empiric antibiotics
source control
hypotension or hypoperfusion → hypotension

clinically stable

treat discomfort, not the number: paracetamol 1 g PO q6h, max 4 g/day; IV only if not tolerating oral
lower the maximum in liver disease, low body weight, frailty or malnutrition

reassess

vitals trend, culture results; positive culture → narrow to sensitivities
review every IV antibiotic at 48 h; switch to oral early
not improving → think beyond infection: drug fever, transfusion reaction, PE, malignancy, autoimmune disease, postoperative inflammation
escalate → ID for resistant organisms or no source; senior if deteriorating

hand over → source, antibiotics started, cultures pending, 48 h review due, escalation trigger

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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reviewed Aug 2026updated Oct 2026file vital/fever