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

* 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

Resources

* BPAC common antibiotics guideline (2017)

* The Third International Consensus Definitions for Sepsis and Septic Shock