Fever In Hospitalised Patients

Question 1

What is the definition of a fever?

Answer 1

> /= 38°C

Question 2

How does temperature vary daily?

Answer 2

Circadian rhythm - highest in afternoon (<37.8°C), lowest in morning (<37.2°C)

Healthy range of temperature: 35.6-38.2 °C (only 8% of people have a normal temp of 37°C)

Question 3

What is the clinical approach to fever?

Answer 3

Non-infectious:
-Causes of inflammation
- Thromboembolic disease
- Bedsores
- Infarction (CVA/MI/PVD)
- IRIS
- Drug induced fever

Infectious:
- Systems + aetiology approach

Question 4

What is the approach to infectious causes of fever?

Answer 4

Consider the systems:

• Skin +soft tissue
• Respiratory
• GIT
• Intra-abdominal
• Urinary tract
• CNS
• Vascular

Question 5

What are the causes of skin and soft tissue infections causing fever in hospital?

Answer 5

• Drip site infection
• Surgical site infection
• Infected bed sores

Caused by the bacteria that live on the skin
(Gram-positive cocci (e.g., staph, strep))
(By bedsores - gram-negative bacilli (E. coli, K. pneumonie, pseudomonas))

History:
- IV catheter
- Post-op
- Immobility

Examination:
- Local cellulitis

Tests:
- Blood culture

Question 6

What are the causes of respiratory infection causing fever in hospital?

Answer 6

Pneumonia

Most commonly bacterial (Pneumococcus, S.aureus, K. pneumoniae)
(Can be viral - influenza, Covid-19)

History:
- Dyspnoea
- Cough
- Risk of aspiration

Examination:
- Tachypnoea
- Crackles

Test:
CXR

Question 7

What are the causes of GIT infection causing fever in hospital?

Answer 7

C. diff diarrhoea
Bacilliary dysentery (Shigella etc.)
Viral diarrhoea

History:
- Antibiotic use
- Diarrhoea

Examination:
- Abdominal tenderness

Tests:
- Antigen/toxin
- PCR

Question 8

What are the causes of intra-abdominal infection causing fever in hospital?

Answer 8

Post-laparotomy collections

History:
- Recent laparotomy

Examination:
- Abdominal tenderness

Tests:
- Abdominal imaging

Question 9

What are the causes of urinary tract infections causing fever in hospital?

Answer 9

Catheter-associated UTI

Gram-negative bacilli (E coli, K.pneumoniae, P.aeruginosa)

Always consider a UTI, even if there are symptoms from other systems

History:
- Non-specific

Examination:
- Non-specific
- Renal angle tenderness

Tests:
- Urine culture
- Blood culture

Question 10

What are the causes of CNS infection causing fever in hospital?

Answer 10

Meningitis (post-op)
Brain abcess

History:
- New neurological symptoms
- Confusion
- Drowsiness

Examination:
- Neck stiffness

Tests:
- CSF exam (cells, culture)

Question 11

What are the causes of vascular infection causing fever in hospital?

Answer 11

Endocarditis (drip site)
Post-op graft infection

History:
- IV catheter
- Vascular surgery

Examination:
- Murmurs

Test:
- Blood culture
- Echo

Question 12

How do you manage urinary catheters to avoid infection?

Answer 12

Only put catheter in if indicated!

• Acutely ill patient that needs monitoring of output
• Urinary retention (obstruction/neuropathy)
• Local wounds requiring intensive care

When inserting use:
- Hand hygiene
- Sterile technique
- Smallest catheter possible
- Secure properly

Once in:
- Collect fresh urine only from sampling port using sterile needle and syringe
- Empty bad regularly
- Keep bag below level of bladder, suspend off floor

DONT’S:
- Clean meatus with antiseptic
- Screen for or treat asymptomatic bacteruria
- Use systemic antibiotics as prophylaxis
- Change or irrigate catheters routinely

Question 13

How do you manage an IV line to prevent infection?

Answer 13

Only if indicated!
- IV antibiotics
- IV fluids/nutrition
- IV therapy

On insertion:
- Hand hygiene
- Sterile technique
- Smallest needle possible
- Secure properly

Once in:
- Examine daily for signs of inflammation
- Remove if signs of inflammation
- Remove when drip tissues -> discard and replace