Fever and infection
Sam talks to Infectious Diseases Physician Assoc. Prof Mark Thomas about fever and the minutiae of microbiological investigations.
Cause of fever
- Infection (cytokines)
- Atelectasis
- Medications including transfusion reaction
- Alcohol withdrawal
- PE
- Malignancy
Approach
- Eyeball the patient / ABCs
- History should be directed at identifying evidence of infection across the following systems:
- Lungs
- Gastrointestinal
- Genitourinary
- Skin
- Central nervous system
- Surgical and cannula/drain sites
- Note: eyes, ears, nose throat are rare infection sources in an adult hospital setting
- Identify timing since surgery or invasive procedures.
- Dirty surgery may cause early infection, but is rare with routine prophylactic antibiotics.
- 2-7 days post-op increased risk of operative infection
- 7+ days think alternatives like PE as well as intrabdominal collection and joints
- Identify risk factors for deteriorating quickly
- Diabetes
- Neutropenia
- Immune deficiency
- Vitals + Examination
- General inspection + peripheries
- Lungs
- Abdomen
- Skin (including spinal anaesthesia sites)
- Surgical and cannula sites
- CNS if history supports it (though beware the non-specificity of classical meningism)
- Investigations
- Review microbiology for updated reports
- FBC, U&E, CRP
- ABG for sepsis
- Directed culture
- Blood
- At least 2 setsv(4 bottles)
- Urine
- Faeces
- Sputum
- Blood
- Directed imaging
- CXR
- CT abdo pelvis
- Renal USS for renal abscess in urosepsis
- Management
- Fluids
- Antibiotics
- Oxygen if desaturating
- Contact precautions
- Investigations/culture
- Document
- Review past notes
- Basics (date/time/name/reason for review)
- Positives and pertinent negatives by system
- Impression and differential with justification. Have you eliminated life threatening conditions?
- Clear and specific plan
- Who will chasing investigations?
- Monitoring parameters
- Consider discussion with senior and escalation, especially if called back to patient again or there are concerns about source control or neutropenia