Fever

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    Last updated: December 2023

     

    Fever is defined as an axillary temperature higher than 37.5 °C.

    Fever is frequently due to infection. In a febrile patient, first look for signs of serious illness then, try to establish a diagnosis.

    Signs of severity

    • Petechial or purpuric rash, meningeal signs, heart murmur, severe abdominal pain, dehydration.
    • Signs of severe bacterial infection or sepsis: critically ill appearance a Citation a. Critically ill appearing child: weak grunting or crying, drowsiness, difficult to arrouse, does not smile, disconjugate or anxious gaze, pallor or cyanosis, general hypotonia. , hypothermia, altered level of consciousness, severe tachycardia, hypotension, tachypnoea, respiratory distress, seizures; a bulging fontanel in young children.
    • Signs of circulatory impairment or shock: see Shock, Chapter 1. 

    Infectious causes of fever according to signs and symptoms

    Signs or symptoms

    Possible aetiology

    Meningeal signs, seizures

    Meningitis/meningoencephalitis/severe malaria

    Abdominal pain or peritoneal signs

    Appendicitis/peritonitis/enteric fevers/amaebic liver abscess

    Diarrhoea, vomiting

    Gastroenteritis/enteric fevers

    Jaundice, enlarged liver

    Viral hepatitis

    Cough

    Pneumonia/measles/tuberculosis if persistent

    Eyelid erythema, eye pain and oedema Orbital cellulitis

    Ear pain, red tympanic membrane

    Otitis media

    Tender swelling behind the ear Mastoiditis

    Sore throat, enlarged lymph nodes

    Streptococcal pharyngitis/diphtheria/retropharyngeal or tonsillar abscess/epiglotittis

    Multiple vesicles on the oral mucosa and lips Oral herpes

    Dysuria, urinary frequency, back pain

    Urinary tract infection

    Red, warm, painful skin

    Erysipelas/cellulitis/necrotising infections of the skin and soft tissues/abscess

    Limp, difficulty walking

    Osteomyelitis/septic arthritis

    Rash

    Measles/dengue/viral haemorrhagic fevers/chikungunya

    Bleeding (petechiae, epistaxis, etc.)

    Dengue/viral haemorrhagic fevers/severe malaria

    Joint pain

    Rheumatic fever/chikungunya/dengue

     

    • If the patient is ill appearing a Citation a. Critically ill appearing child: weak grunting or crying, drowsiness, difficult to arrouse, does not smile, disconjugate or anxious gaze, pallor or cyanosis, general hypotonia. and has a persistent fever, consider HIV infection and tuberculosis, according to clinical presentation.

    Laboratory and other examinations

    • Malaria rapid diagnostic test in endemic areas.
    •  In case of circulatory impairment or shock: see Shock, Chapter 1.  
    • Children 1 to 3 months with fever without a focus:
      • urine dipstick and urine culture, if available;
      • blood culture, if available;
      • full blood count (FBC), if available;
      • lumbar puncture (LP) if meningeal signs or signs of severe bacterial infection or sepsis, or failure of prior antibiotic treatment;
      • chest x-ray, if available, in case of signs of respiratory disease or severe infection or sepsis.
    • Children > 3 months to 2 years with fever without a focus:
      • urine dipstick and urine culture, if available;
      • LP if meningeal signs or signs of severe bacterial infection or sepsis;
    • chest x-ray, if available, if fever > 72 hours or signs of severe bacterial infection or sepsis;
    • blood culture, if available, if fever > 72 hours or signs of severe bacterial infection or sepsis;
    • FBC, if available, if fever > 72 hours or signs of severe bacterial infection or sepsis;
    • other: according to clinical presentation.
    • Children over 2 years with fever without a focus:
      • urine dipstick and urine culture, if available, if history of urinary tract infection or fever > 72 hours or signs of severe bacterial infection or sepsis;
      • LP if meningeal signs or signs of severe bacterial infection or sepsis;
      • chest x-ray, if available, if fever > 72 hours or signs of severe bacterial infection or sepsis;
      • blood culture, if available, if fever > 72 hours or signs of severe bacterial infection or sepsis;
      • FBC, if available, if fever > 72 hours or signs of severe bacterial infection or sepsis;
      • other: according to clinical presentation.
    • Adults: according to clinical presentation.

    Aetiological treatment

    • Treat patients with a positive malaria test: see Malaria, Chapter 6.
    • If the source of infection has been found: administer antibiotic treatment accordingly.
    • If severe infection, sepsis, circulatory impairment or shock: hospitalise and immediately administer an empiric antibiotic treatment (see Shock, Chapter 1). Continue this treatment until the source of infection is found and adapt antibiotic treatment accordingly.

    • If no source of infection is found, and there are no signs of severe infection, sepsis, circulatory impairment or shock, hospitalise for further investigations and monitoring:
      • Children 1 to 3 months;
      • Children > 3 months to < 2 years with negative urine dipstick (and negative urine culture if available).
    • For malnourished children, see Severe acute malnutrition, Chapter 1.

    • For patients with sickle cell disease, see Sickle cell disease, Chapter 12.

    Symptomatic treatment

    • Undress the patient. Do not wrap children in wet towels or cloths (not effective, increases discomfort, risk of hypothermia).
    • Antipyretics may increase the patient’s comfort but they do not prevent febrile convulsions. Do not treat for more than 3 days with antipyretics.

    paracetamol PO 
    Children 1 month and over: 15 mg/kg 3 to 4 times daily (max. 60 mg/kg daily)
    Adults: 1 g 3 to 4 times daily (max. 4 g daily)
    or
    ibuprofen PO
    Children over 3 months and < 12 years: 5 to 10 mg/kg 3 to 4 times daily (max. 30 mg/kg daily)
    Children 12 years and over and adults: 200 to 400 mg 3 to 4 times daily (max. 1200 mg daily)
    or
    acetylsalicylic acid (ASA) PO
    Children over 16 years and adults: 500 mg to 1 g 3 to 4 times daily (max. 4 g daily)

    Prevention of complications

    • Encourage oral hydration. Continue frequent breastfeeding in infants.
    • Look for signs of dehydration.
    • Monitor urine output.

     

    Notes:

    • In pregnant or breast-feeding women use paracetamol only.
    • In case of viral haemorrhagic fevers and dengue: acetylsalicylic acid and ibuprofen are contraindicated; use paracetamol with caution in the presence of hepatic dysfunction.

     

    Footnotes
    • (a) Critically ill appearing child: weak grunting or crying, drowsiness, difficult to arrouse, does not smile, disconjugate or anxious gaze, pallor or cyanosis, general hypotonia.