Fever
ABCs
- check vitals and random blood glucose
- recheck temperature (oral / axillary vs tympanic discrepancies)
- assess deterioration signs: hypotension, tachypnea, desaturation, confusion
- escalate if patient in shock
escalate early
- hemodynamic instability
- tachypnea or desaturation
- confusion or new altered mental status
- neutropenic patient
HPI
- onset, duration, pattern
- fever details → new vs persistent, trend, measurement method
- identify focal infection source
- sick contacts or food exposure
- chart review
- current infection treatment
- antibiotic use
- admission length
- MRSA or Pseudomonas risk
- immunocompromised status
- renal function-adjusted dosing
- prior 24 hours → surgery, line insertion, new medications, ICU transfer
system review
- CNS → headache, confusion, seizures, N/V, photophobia, neck stiffness
- ENT → purulent ear discharge, sinus tenderness, mastoid pain
- cardiac → pleuritic chest pain (positional relief), new murmur
- respiratory → cough, dyspnea, hemoptysis, chest pain, aspiration risk, ventilator changes
- GI → abdominal pain, bowel changes, N/V
- skin / soft tissue → cellulitis, ulcers, sores, cannula or surgical sites
- rheum / MSK → joint swelling, joint pain, rash, myalgia, bone pain
- GU → dysuria, hematuria, frequency, flank pain
- gyne → vaginal discharge, pelvic pain
- devices → pacemaker, PEG, Foley, central line, tracheostomy sites
examination
- system-tailored approach
- don’t omit → joint assessment, cannula/wound inspection, chest and cardiac auscultation, surgical site palpation
workup
review available investigations
- leukocytosis or neutropenia
- CRP or PCT trends
- previous culture results
- recent viral swab results
- CXR findings
if stable
- CBC with differential, CRP ± PCT
- trace pending cultures, viral swabs
- CXR
- monitor trends
if new, unwell, or worsening (full septic screen)
- CBC, CRP, PCT, LFT, RFT, lactic acid
- urinalysis + culture
- stool culture ± C. difficile testing
- blood cultures × 2 (different sites)
- sputum culture ± endotracheal aspirate
- wound or ulcer swab
- line tip culture if removed
- soft tissue ultrasound (if needed)
- CXR
- consider surgical referral (diabetic foot, ulcers)
calculator SIRS / sepsis · MDCalc ↗︎
management
febrile neutropenia, do not wait
- any fever in a neutropenic patient = emergency
- start an antipseudomonal β-lactam within 60 min → piperacillin-tazobactam 4.5 g IV q6h (or cefepime 2 g IV q8h)
- add vancomycin 15 mg/kg IV q12h only for line infection, skin/soft-tissue, mucositis, or instability
- send cultures first only if this does not delay the first dose; discuss with Microbiology / ID
clinically stable and investigated
- reassess pending results
- paracetamol 1 g IV q6h (max 4 g/day, less in liver disease)
new onset, unwell, or deteriorating
- send cultures first (if safe)
- start empiric antibiotics early
- adjust dosing for renal function
antibiotic selection
- site of infection
- severity level
- immune status
- prior cultures and resistance patterns
- local resistance patterns
- MRSA or Pseudomonas risk
- consider Microbiology / ID consult if complex
if called about positive cultures
- verify appropriate antibiotic coverage
- review organism sensitivities
- adjust antibiotic choice
- repeat CBC and CRP for response
- consider Microbiology / ID consult
- review dose and duration
empiric antibiotics by source
- confirm against current local policy
- community-acquired pneumonia, ward → moxifloxacin 400 mg IV/PO q24h or levofloxacin 750 mg IV/PO q24h; or ceftriaxone 1–2 g IV q24h + azithromycin 500 mg q24h (ICU: ceftriaxone + macrolide)
- hospital-acquired pneumonia → piperacillin-tazobactam 4.5 g IV q6h or cefepime 2 g IV q8h; add vancomycin 15 mg/kg q12h (or linezolid 600 mg q12h) if MRSA risk
- febrile UTI / complicated urinary → levofloxacin 750 mg IV/PO q24h or piperacillin-tazobactam 4.5 g IV q6h
- biliary (cholangitis / cholecystitis) → piperacillin-tazobactam 3.375 g IV q6h (life-threatening → imipenem 0.5 g IV q6h)
- secondary peritonitis (perforation / abscess) → meropenem 1 g IV q8h, or ceftolozane-tazobactam 1.5 g IV q8h + metronidazole 500 mg q8h
- spontaneous bacterial peritonitis → ceftriaxone 2 g IV q24h
- cellulitis, extremities → penicillin G 1–2 MU IV q6h (or cefazolin 1 g IV q8h); facial or MRSA risk → vancomycin 15–20 mg/kg q12h
- necrotizing fasciitis → vancomycin 15–20 mg/kg IV q8–12h + piperacillin-tazobactam 3.375 g IV q6h + clindamycin 900 mg q8h; urgent surgery
- meningitis → ceftriaxone 2 g IV q12h + vancomycin 15–20 mg/kg q12h ± dexamethasone 10 mg IV (≈0.15 mg/kg) q6h ×4 days; add ampicillin 2 g IV q4h if >50 y or immunocompromised
- central line-associated bloodstream → vancomycin 15 mg/kg IV q12h + cefepime 2 g IV q8h (femoral line → add anidulafungin); consider line removal
- source unclear → identify and treat per the relevant section; if truly unknown, broad-spectrum per Micro advice (e.g. piperacillin-tazobactam 4.5 g IV q6h ± vancomycin if MRSA risk)
- always: cultures before antibiotics where safe · review all IV antibiotics at 48 h · IV→PO switch early · renal-adjust with pharmacy · discuss with Micro if unsure
studying for the IM exam? the IM Rapid Review covers fever workup and sepsis in the same format. see the sample chapter.
Last reviewed · June 2026