LEARNING OBJECTIVES:

• Define fever
• Identify the significance of fever in hospitalized patients:
  • with neutropenia
  • with HIV/AIDS
  • on steroids
• List the common sources/sites of infection in febrile hospitalized patients.
• List the common pathogens responsible for infection in febrile hospitalized patients.
• List the likely sites/pathogens for nosocomial infections in febrile hospitalized patients.
• List the common infectious causes of fever in patients with HIV/AIDS as predicted by CD4 counts.
• Formulate a diagnostic plan to evaluate the various causes of fever in a febrile hospitalized patient:
  • with indwelling devices or hardware
  • post-operatively
  • fever of unknown origin
• List the common sources/pathogens responsible for catheter-related infections in neutropenic hosts.
• List indications for invasive procedures for evaluation of fever in the neutropenic host.
• Identify patients who warrant empiric antibiotic therapy.
• Identify the appropriate antibiotic or antifungal therapy for the clinical situation at hand:
  • based on suspected source or pathogen
  • in the febrile neutropenic patient
  • based on age, renal function and obesity
  • in the patient recently hospitalized or institutionalized
  • in the patient with parapneumonic effusion
• Identify the risks of inappropriate antibiotic therapy
• List risk factors for transmission of HIV
• Recognize the morbidity/mortality associated with various causes of nosocomial infection.
• Recognize common pathogens in community-acquired infections.
• Identify strategies to prevent nosocomial infection including catheter-associated infections.

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PATIENT CARE AND COMMUNICATION SKILLS

HISTORY:

• Students should be able to obtain history of onset of illness with particular emphasis on exposure to other ill people, travel history, history of pets and occupation and prior opportunistic infections. Medications and allergies should also be investigated.

• A thorough review of systems to elicit constitutional symptoms suggestive of occult infections, with particular emphasis on weight loss, chronic respiratory and gastrointestinal complaints. Assessment of functional ability.

• Assessment of socio-economic status and appreciation of its influence on risk of various infectious diseases.

PHYSICAL EXAMINATION:

• Special emphasis on examination of the integument for appearance of rash, papular, petechial, purpuric and nodular lesions. Previous sites of IV or urinary catheters are also important considerations. Presence/Absence of lymphadenopathy. Examination of mucosal areas, axillary and perineal regions.

• Evaluation of cardiac, pulmonary systems, appreciate presence of hepatosplenomegaly.

IMAGING:

• Chest radiography: Distinguish between focal airspace disease, interstitial disease and cavitary disease.

• Four views of the abdomen, appreciate presence of free air and thumb printing of bowel wall.

LABORATORY INTERPRETATION:

• CBC and differential.
   
• Electrolytes, acid base balance, renal function, liver function.

PROCEDURES:

• Insertion of peripheral venous catheter.
   
• Obtain sputum for gram stain.
   
• Obtain blood cultures.

MANAGEMENT:

• Design empiric therapy for neutropenic fever. Adjust dose based on body weight, age, renal function and hepatic function. Adjust antimicrobials based on susceptibility data.

• Institute appropriate isolation procedures based on category of illness and risk of infection.

• Determine the need for invasive diagnostic procedures.

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ATTITUDES AND PROFESSIONAL BEHAVIORS:

• Appreciate the urgency of intervention in neutropenic fever and the potentially fatal nature of illness.

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REFERENCES:

1. Pizzo PA. Drug therapy: Management of fever in patients with cancer and treatment induced neutropenia. NEJM 1993;388:1323-32.
2. Pizzo PA. Current concepts: Fever in Immunocompromised Patients. NEJM 1999;341:893-900.
3. Shelhamer JH, et al. NIH Conference. Respiratory Disease in the Immunosuppressed Patient. AnnInternMed 1992;117:415‑31.
4. Schooley RT. Acquired Immunodeficiency Syndrome, Chapter 11 in Scientific American Medicine.
5. Masur H. Prevention and Treatment of Pneumocystis Pneumonia. NEJM 1992;327:1853-60.
6. Kovacs JA, Masur H. Prophylaxis Against Opportunistic Infections in Patients with Human Immunodeficiency Virus Infection. NEJM 2000;342:1416-1429
7. United States Department of Public Health and Human Services and the Henry J. Kaiser Family Foundation. Guidelines for the Use of Antiretroviral Agents in HIV-infected Adults and Adolescents. www.hivatis.org/trtgdlns.html.
8. International AIDS Society - USA Panel. Antiretroviral Therapy in Adults. JAMA 2000; 283:381-390.
9. Murphy RL. Clinical aspects of HIV infection and AIDS: prevention and treatment of opportunistic infections. CurrOpinInfectDis 1994;7:108-113.
10. Murphy RL. Clinical aspects of human immunodeficiency virus disease: clinical rationale for treatment. JInfectDis 1995;171(Suppl 2):S81-87.

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