Priority Topic: Antibiotics, Priority Topic: Fever, Priority Topic: Infections, & Priority Topic: Urinary Tract Infection
Key Feature 5: In urgent situations (ex: cases of meningitis, septic shock, febrile neutropenia), do not delay administration of antibiotic therapy (i.e., do not wait for confirmation of the diagnosis).
Key Feature 6: Aggressively and immediately treat patients who have fever resulting from serious causes before confirming the diagnosis, whether these are infectious (ex: febrile neutropenia, septic shock, meningitis) or non-infectious (ex: heat stroke, drug reaction, malignant neuroleptic syndrome).
Key Feature 7: In the febrile patient, consider causes of hyperthermia other than infection (ex: heat stroke, drug reaction, malignant neuroleptic syndrome).
Skill: Clinical Reasoning
Phase: Hypothesis generation, Diagnosis
Key Feature 3: Treat infections empirically when appropriate (ex: in life threatening sepsis without culture report or confirmed diagnosis, candida vaginitis post-antibiotic use).
Skill: Clinical Reasoning, Selectivity
Key Feature 6: When treating infections with antibiotics use other therapies when appropriate (ex: aggressive fluid resuscitation in septic shock, incision and drainage abscess, pain relief).
Skill: Clinical Reasoning
In my last post I talked about how there is not always a need to empirically treat a fever if we don't know what the cause is. This is based on the patient in front of you appearing rather well. If, on the other hand, the patient does not appear well, or has risk factors for not being able to compensate in a way that an otherwise healthy person would, or if, based on your clinical assessment or preliminary workup you think the cause may cause a serious threat to life, then treating empirically is indicated.
If aggressive and immediate treatment for fever or hyperthermia is warranted, treatment may need to be started without knowing what the reason is for the core body temperature elevation. Per the UpToDate article, Pathophysiology and treatment of fever in adults (2018), "Although the vast majority of patients with elevated body temperature have fever, there are a few instances in which an elevated temperature represents hyperthermia. (...) There is no rapid way to differentiate elevated core temperature due to fever from hyperthermia. The immediate events prior to the onset of hyperthermia usually play an important role in determining its cause." So it is important to gather a basic history to look for any clues suggestive that the patient has hyperthermia rather than a fever as there will be some different steps to consider in treating such a patient. I will outline my approach here to the patient with hyperthermia, while my approach to the febrile patient was covered in my last blog post*. Both possibilities may need to be worked up at the same time.
Approach to a patient with suspected hyperthermia:
I have only once encountered a patient in an emergency medicine rotation (in medical school) who presented with hyperthermia. It was the prototypical elderly lady who spent a good chunk of the day gardening in the sun. She was a bit dehydrated, and so we gave her IV fluids. She responded well, and it was fairly uncomplicated. My hope is to never need to apply the above approach, but to still be prepared should I encounter a patient with serious hyperthermia in the future.
*In my last blag post, I described an approach to working up a fever of unknown origin, but I didn't really talk about management of what to do in the interim when waiting for the results of diagnostic testing. If the patient appears unwell or is someone who would be at risk of decompensating or of not being able to tolerate decompensation, then gather your swabs etc. and begin empiric broad spectrum antibiotics. What does this looks like? My rules of thumb are as follows (with a description of the bugs they typically cover), but if you are more suspicious of certain types of infections, you can obviously tailor your empiric antibiotics accordingly.