eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease
Fever Without a Focus: Treatment & Medication
Updated: Jan 22, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
For children with fever without a focus who appear ill, conduct a complete evaluation to identify occult sources of infection. Follow the evaluation with empiric antibiotic treatment and admit the patient to a hospital for further monitoring and treatment pending culture results.
Patients aged 2-36 months may not require admission if they meet the following criteria:
- Patient was healthy prior to onset of fever.
- Patient has no significant risk factors.
- Patient appears nontoxic and otherwise healthy.
- Patient's laboratory results are within reference ranges defined as low risk.
- Patient's parents (or caregivers) appear reliable and have access to transportation if the child's symptoms should worsen.
Treatment recommendations for children with fever without a focus are based on the child's appearance, age, and temperature.
- For children who do not appear toxic, treatment recommendations are as follows:
- Consider no antibiotics; however, if absolute neutrophil count is greater than 10,000/μ L, consider ceftriaxone (50 mg/kg/dose).
- Schedule a follow-up appointment within 24-48 hours and instruct parents to return with the child sooner if the condition worsens.
- Hospital admission is indicated for children whose condition worsens or whose evaluation findings suggest a serious infection.
- For children who appear toxic, treatment recommendations are as follows:
- Admit child for further treatment; pending culture results, administer parenteral antibiotics.
- Initially administer ceftriaxone, cefotaxime, or ampicillin/sulbactam (50 mg/kg/dose).
Consultations
The need to consult with specialists depends on the specialty of the physician who initially evaluated the patient and the ultimate source of fever. Typically, general pediatricians easily manage febrile infants on both an inpatient and outpatient follow-up basis.
Diet
Patient tolerance is the only restriction on diet. Physicians should monitor intake and output as an indication of the patient's status because these measurements may provide the first evidence of a disturbance that indicates illness.
Activity
Patient tolerance also determines activity level, which should be monitored for changes (eg, lethargy, irritability).
Medication
Treatment with antipyretics is somewhat controversial because fever is a defensive response to infection. Base the decision to treat a fever without a focus on age, presentation, and laboratory results. If antibiotics are administered empirically, close follow-up is required. Parenteral antibiotics are the drugs of choice.
Antibiotics
Empiric antimicrobial therapy must be comprehensive and should cover likely pathogens in the clinical setting.
Ceftriaxone (Rocephin)
Third-generation cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms; arrests bacterial growth by binding to one or more penicillin-binding proteins.
Adult
1-2 g IV q12-24h; not to exceed 4 g/d
Pediatric
>1-2 months and children: 50-100 mg/kg/d IV/IM divided q12h; not to exceed 2 g/d
Probenecid may increase levels; coadministration with ethacrynic acid, furosemide, or aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment; caution in breastfeeding women and those allergic to penicillin; displaces bilirubin from serum protein-binding sites and should be used with caution in infants <2 mo and in those with hyperbilirubinemia or gallbladder problems
Cefotaxime (Claforan)
For septicemia and treatment of gynecologic infections caused by susceptible organisms. Arrests bacterial cell wall synthesis, which, in turn, inhibits bacterial growth. Third-generation cephalosporin with gram-negative spectrum. Lower efficacy against gram-positive organisms. Useful in pediatric infections as an alternative to ceftriaxone in infants in the first month or two of life, in whom bilirubin displacement from protein-binding sites by the latter antibiotic may be harmful.
Adult
Moderate-to-severe infections: 1-2 g IV/IM q6-8h
Life-threatening infections: 1-2 g IV/IM q4h
Pediatric
Infants and children: 50-200 mg/kg/d IV/IM divided q4-6h
>12 years: Administer as in adults
Probenecid may increase levels; coadministration with furosemide and aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Use with caution in patients with documented hypersensitivity to beta-lactams; adjust dose in severe renal impairment; has been associated with severe colitis
Ampicillin/sulbactam (Unasyn)
Drug combination of beta-lactamase inhibitor with ampicillin. Covers skin, enteric flora, and anaerobes. Not ideal for nosocomial pathogens.
Adult
1.5 (1 g ampicillin + 0.5 g sulbactam) to 3 g (2 g ampicillin + 1 g sulbactam) IV/IM q6-8h; not to exceed 4 g/d sulbactam or 8 g/d ampicillin
Pediatric
3 months to 12 years: 100-200 mg ampicillin/kg/d (150-300 mg Unasyn) IV divided q6h
>12 years: Administer as in adults; not to exceed 4 g/d sulbactam or 8 g/d ampicillin
Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of PO contraceptives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction
Antipyretic agents
These agents inhibit central synthesis and release of prostaglandins that mediate the effect of endogenous pyrogens in the hypothalamus and, thus, promote the return of the set-point temperature to normal.
Ibuprofen (Advil, Motrin)
Among the few NSAIDs indicated for reduction of fever; produces anti-inflammatory, antipyretic, and analgesic effects by inhibiting prostaglandin synthesis.
Adult
200-800 mg PO q6-8h prn; not to exceed 3.2 g/d
Pediatric
4-10 mg/kg/dose PO tid/qid; not to exceed 40 mg/kg/d or 2.4 g/d
>12 years: Administer as in adults
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
Acetaminophen (Tempra, Tylenol)
Reduces fever by acting directly on hypothalamic heat-regulating centers, which increases dissipation of body heat via vasodilation and sweating.
Adult
325-650 mg PO q4-6h or 1000 mg PO tid/qid; not to exceed 4 g/d
Pediatric
<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: Administer as in adults
Rifampin can reduce analgesic effects; coadministration with barbiturates, carbamazepine, hydantoins, or isoniazid may increase hepatotoxicity
Documented hypersensitivity; known G-6-PD deficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity possible following various dose levels in individuals with chronic alcoholism; severe or recurrent pain or high or continued fever may indicate a serious illness; contained in many OTC products; combined use with these products may result in cumulative doses exceeding recommended maximum dose
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| Overview: Fever Without a Focus |
| Differential Diagnoses & Workup: Fever Without a Focus |
 Treatment & Medication: Fever Without a Focus |
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Further Reading
Keywords
fever without a focus, bronchiolitis, childhood fever, croup, cyanosis, end-stage renal disease, Escherichia coli, fever without a source, fever without localizing signs, gingivostomatitis, Haemophilus influenzae type b, hand-foot-and-mouth disease, hyperventilation, hypoventilation, Listeria monocytogenes, meningitis, Neisseria meningitidis, occult bacteremia, otitis media, pediatric fever, pharyngitis, pneumonia, pyelonephritis, renal failure, renal scarring, sinusitis, Streptococcus agalactiae, Streptococcus pneumoniae, urinary tract infection, UTI, varicella, viral gastroenteritis
