Hospital Fever Workup

Initial Clinical Assessment

The Society of Critical Care Medicine recommends performing a targeted evaluation including review of recent procedures, surgeries, and indwelling devices, as well as a focused physical examination of potential infection sites, for any hospitalized patient who develops a new fever 1, 2
A medication review for drug-induced fever is recommended, particularly for patients who have received antibiotics or chemotherapy within 60 days 3, 2

The Society of Critical Care Medicine recommends obtaining a chest radiograph on all febrile patients, as pneumonia is the most common infection causing fever in hospitalized patients 1, 4
Blood cultures should be collected at least two sets (ideally 60 mL total) from different anatomical sites simultaneously, and if a central venous catheter is present, draw simultaneously from catheter and peripheral site to calculate differential time to positivity 1, 5

For suspected urinary tract infection, replace urinary catheter and obtain urine culture from newly placed catheter if pyuria is present, and avoid routine urine cultures in catheterized patients without symptoms 1, 5, 2
For suspected pneumonia or respiratory symptoms, obtain lower respiratory tract specimen before antibiotic initiation, and consider viral nucleic acid amplification testing if upper respiratory symptoms are present 3, 2, 1, 5
For diarrhea, test for Clostridium difficile toxin if patient received antibiotics or chemotherapy within 60 days, and avoid routine stool cultures for other bacteria unless patient admitted with diarrhea or is HIV-positive 3, 2

If initial workup fails to identify etiology, consider 18F-FDG PET/CT if transport risk is acceptable, with a sensitivity of 85-100% 4, 6
Thoracic ultrasound may help identify pleural effusions if chest X-ray is abnormal and expertise is available 1, 4

When bacterial infection probability is low-to-intermediate, measure procalcitonin (PCT) or C-reactive protein (CRP) in addition to clinical evaluation, but do not use PCT or CRP to rule out infection when bacterial infection probability is high 1, 5

Avoid automatic order sets that include unnecessary testing, and let clinical assessment guide workup 2
Do not routinely culture urine in catheterized patients without pyuria or UTI symptoms 2
Do not send stool for bacterial culture unless patient admitted with diarrhea, is HIV-positive, or part of outbreak investigation 3

Use core temperature methods when available, such as pulmonary artery catheter thermistor, bladder catheter, or esophageal probe, over less reliable methods like axillary, tympanic, or temporal artery 1, 4