Urgent considerations

See Differentials for more details

Febrile neutropenia and immunocompromised patients

Due to the relatively high prevalence of serious bacterial infections that may be present in immunocompromised or neutropenic patients, empirical antibiotics should be started.[5][18]​​​​ The choice of antibiotic regimen should be based on coverage of the most likely pathogens and local susceptibility patterns (as per local healthcare institution algorithms and guidelines), as well as patient-specific factors (e.g., prior history of antibiotic-resistant infection and allergy history) See Febrile neutropenia (Management approach). Blood cultures should be taken prior to starting treatment, but even if they remain negative, empirical antibiotics are required to cover possible occult infections.

Giant cell arteritis

Patients with suspected giant cell arteritis are treated immediately with corticosteroids until the diagnosis can be excluded with biopsy, due to the risk of visual loss.[19][20]​​ Patients with giant cell arteritis may present with localised headache, visual disturbances and jaw claudication.​[21] On examination, they may have reduced pulse, tenderness, or nodules of the temporal artery. The erythrocyte sedimentation rate is usually elevated, but this is a non-specific finding. Simple algorithms have been devised to aid the diagnosis of giant cell arteritis.[22][23]​​ Temporal artery biopsy is the definitive diagnostic test.

Empirical therapy and therapeutic trials

A fundamental principle in the management of classic FUO is that therapy should be withheld whenever possible until the cause of the fever has been determined so that treatment can be tailored to a specific diagnosis.[1]​​[20][24]​​​ This is based on the observation that non-specific treatment rarely cures FUO and has the potential to delay reaching a diagnosis. This is, however, frequently ignored in clinical practice because the road to diagnosis of FUO is often long and frustrating. As a result, clinicians may feel compelled to treat symptoms empirically, even though the agents used may obscure the signs and symptoms on which the diagnosis depends, or potentially exacerbate the problem, as in the case of empirical corticosteroid use in occult infection. An important exception is that empirical corticosteroid treatment may be appropriate in patients with sufficiently clinically suspected giant cell arteritis to prevent vascular complications, such as blindness or stroke.[19][25][26]​​​​​ Primary care physicians may favor a cost-effective approach for managing acute febrile illness and employ empirical antimicrobial therapy before undertaking expensive diagnostic exercises. This approach is less likely to succeed in patients with classic FUO and may obfuscate infectious diagnoses as a cause.

Use of this content is subject to our disclaimer