#1 TREATMENT OF FEVER

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FEVER BASICS AND EXTRA EDGE ............................... 3

WHY TO TREAT FEVER? ............................................ 4

KERALA HEALTH DPT GUIDELINES[COMPILED]..............5

DIFFERENTIALS.......................................................... 7

PUO........................................................................ 15

DRUGS IN FEVER [COMPILED FROM GP BOOK].......... 16

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FEVER BASICS AND EXTRA EDGE, an
elevation in core body temperature above the daily range for an individual, is a
characteristic feature of most infections but is also found in a number of
noninfectious diseases such as autoimmune and autoinflammatory diseases.
●Normal body temperature is low in the early morning and high in evening,
varying 0.5°C (0.9°F) over the course of the day, controlled in the
thermoregulatory center located in the anterior hypothalamus. However, in
some individuals recovering from a febrile illness, this daily variation can be
as high as 1.0°C. During a febrile illness, daily low and high temperature
readings are maintained but at higher levels.
Fever, if oral T >98.9 0F (at AM) or T>99.90F (at PM)
Note: 0C*1.8 +32=0F Note: In case of fever with chills,
suspect UTI, malaria, pneumonia, cellulitis,
abscess,influenza, leptospirosis, dengue,
gastroenteritis, meningitis, tonsillitis, IMN, TB
etc
●The ability to develop fever in older adults is impaired, and baseline
temperature in older adults is lower than in younger adults. Thus, older adult
patients with severe infections may only display a modest fever.
●Although the vast majority of patients with elevated body temperature have
fever, there are a few instances in which an elevated temperature represents
hyperthermia. These include heat stroke syndromes, certain metabolic
diseases, and the effects of pharmacologic agents that interfere with
thermoregulation. It is important to make the distinction between fever and
hyperthermia. Hyperthermia can be rapidly fatal, and its treatment differs from
that of fever.
●Hyperpyrexia is the term for an extraordinarily high fever (>41.5°C), which
can be observed in patients with severe infections but most commonly occurs
in patients with central nervous system hemorrhages.

Patients with autoimmune diseases being treated with biologic agents, such
as tumor necrosis factor-alpha inhibitors, are at increased risk for routine as
well as opportunistic infections. In these patients, a low-grade fever may serve
as an early warning sign of a serious infection.
WHY TO TREAT FEVER?

TREATMENT OF FEVER AND HYPERTHERMIA — Elevated core temperature,

whether fever or hyperthermia increases the demand for oxygen and can
aggravate preexisting cardiac or pulmonary insufficiency. For every increase of
one degree above 37°C, there is a 13 percent increase in O2 consumption. In
addition, elevated temperature can induce mental changes in patients with
organic brain disease. Although a rapid reduction in elevated core temperature
due to hyperthermia is mandatory, treatment of fever is often a debated issue.

Decision to treat fever — The vast majority of fevers are associated with
self-limited infections, most commonly of a viral origin, where the cause of the
fever is easily identified. The decision to reduce fever with antipyretics assumes
that there is no diagnostic benefit of allowing the fever to persist. However, there
are rare clinical situations in which observation of the pattern of fever can be
helpful diagnostically. As an example, the daily highs and lows of normal
temperature are exaggerated in most fevers, but these fluctuations may be
reversed in typhoid fever and disseminated tuberculosis. Temperature-pulse
dissociation (relative bradycardia) is seen in typhoid fever, brucellosis,
leptospirosis, some drug-induced fevers, and factitious fever. In healthy subjects,
the temperature-pulse relationship is linear with an increase in heart rate of
4.4 beats/minute for each 1°C (2.44 beats/minute for each 1°F) rise in core
temperature . Fever may not be present during infection in newborns, older adults,
patients with chronic renal failure, and in patients taking corticosteroids;
hypothermia, in fact, can occur. Hypothermia can also be observed in patients
with septic shock.

Some febrile diseases have characteristic patterns. Among these are malaria and
cyclic neutropenia. However, most of the febrile illnesses that are thought to
exhibit a specific time-related pattern (eg, Hodgkin lymphoma) are in fact, upon
close examination, not reliable indicators or are of no diagnostic value.
KERALA HEALTH DPT GUIDELINES
Differential diagnosis of fever
Differential diagnosis of fever
without localizing signs
Diagnosis In favour
Malaria
• Sudden onset of fever with rigors followed by sweating
•Blood smear positive
• Rapid diagnostic test POSITIVE[not
relevant in highly prevalent areas]
• Severe anaemia
• Enlarged spleen
Septicaemia • Seriously ill and
obviously ill with no apparent cause
• Purpura, petechiae
• Shock or hypothermia in severely
malnourished
Typhoid • Seriously and obviously ill
with no apparent cause
• Abdominal tenderness
• Shock
• Confusion
Urinary tract infection •
Costo-vertebral angle or suprapubic
tenderness
• Crying on passing urine
• Passing urine more frequent than
usual
• Incontinence in previously
continent child
• White blood cells and/or bacteria
in urine or microscopy

Differential diagnosis of fever with

localizing signs
Diagnosis In favour
Meningitis • Fever with headache,
vomiting
• Convulsions
• Stiff neck
• Bulging fontanelle
• Meningococcal rash (petechial or
purpuric)
Otitis media • Red immobile
eardrum on otoscopy
• Pus draining from ear
• Ear pain
Mastoiditis • Tender swelling above
or behind ear
Osteomyelitis • Local tenderness
• Refusal to move the affected limb
• Refusal to bear weight on leg

Septic arthritis • Joint hot, tender,

swollen
Pneumonia • Cough with fast
breathing
• Lower chest wall indrawing
• Fever
• Coarse crackles
• Nasal fl aring
• Grunting
Viral upper respiratory
tract infection
• Symptoms of cough/cold
• No systemic upset
Differential diagnosis of fever with
rash
Diagnosis In favour Diagnosis In
favour
Measles • Typical rash
(maculopapular)
• Cough, runny nose, red eyes
• Recent exposure to a
measles case
• No documented measles
immunization
Meningococcal
infection
• Petechial or purpuric
rash
• Bruising
• Shock
• Stiff neck (if meningitis)
Viral infections • Mild transient
upset
• Transient non-specifi c rash
Dengue
haemorrhagic
fever
• Abdominal tenderness
• Skin petechiae
• Bleeding from nose or
gums or GI bleed
• Shock

Additional differential diagnosis* of

fever lasting longer than 7 days
Diagnosis In favour Diagnosis In
favour
Abscess • Fever with no obvious
focus of infection (deep
abscess)
• Tender or fl uctuant mass
• Local tenderness or pain
• Specifi c signs depend
on site subphrenic, liver,
psoas, retroperitoneal,
lung, renal, etc.
Infective
endocarditis
• Weight loss
• Enlarged spleen
• Anaemia
• Heart murmur
• Petechiae
• Splinter haemorrhages in
nailbeds
• Microscopic haematuria
• Finger clubbing
Rheumatic
fever
• Heart murmur which
may change over time
• Arthritis/arthralgia
• Cardiac failure
• Fast pulse rate
• Pericardial friction rub
• Chorea
• Recent known
streptococcal infection
Tuberculosis • Weight loss
• Anorexia, night sweats
• Cough
• Enlarged liver and/or spleen
• Family history of TB
• Chest X-ray suggestive of
TB
• Tuberculin test positive
• Lymphadenopathy
PUO
Fever of unknown origin (FUO) is defined as fever higher than 38.3ºC on several
occasions lasting for at least three (some use two) weeks without an established
etiology despite intensive evaluation and diagnostic testing

Three general categories of illness account for the majority of "classic" FUO cases
and have been consistent through the decades. These categories are infections,
malignancies, and connective tissue diseases

minimum diagnostic evaluation: blood cultures, erythrocyte sedimentation rate or

C-reactive protein, serum lactate dehydrogenase, HIV antibody test and viral load,
rheumatoid factor, heterophile antibody test, creatine phosphokinase, antinuclear
antibo or interferon-gamma release assay, serum protein electrophoresis, and
computed tomography scan of abdomen and chest.

The primary evaluation and diagnostic workup may suggest an appropriate site for
biopsy that could establish the diagnosis
Drugs in fever
[Credits]

1.inj P mol 2cc (150 /1 ml) im st (if

t>1000 F). 100 ml(1000mg) infusion
available(T.N Paracip)
[for children 10-15
mg/kg/dose,1.5cc/1cc im st] (for
infants and small children give
suppositories (T N:-Anamol),
normally available as
80,125,170,250 mg; for <5 kg not
recommended); Inj Dolonex
(piroxicam) 2cc IM st ATD if allergic
to P/L
2.Tepid sponging with luke warm
water st & SOS;give IV fluids for very
high fever.
3.Do BRE,ESR/CRP,URE , if infection
is suspected & give Antibiotics for
infection
4.T or Syp Meftal may be given Stat
for high fever
5.Antiulcerants(especially if certain
antibiotics like macrolides, NSAIDs,
steroids are
provided).
6.Multivitamin tablets with Vit B
complex, vit C.
7.Steam inhalation for relieving ENT
congestion
Antibiotics
Note:In general, for mild infections
use milder antibiotics
1.C Mox or Novamox 500mg 1-1-1 x
5 days (amoxicillin)
Indications:for RTI including
bronchitis,sinusitis,otitis media, UTI
2.C Roscillin 500mg 1-1-1-1 x 5 days
(ampicillin)
Indications:for RTI including
bronchitis,sinusitis,otitis media, UTI
3.C or T Augmentin/Augpen/Mox CV
625/375 1-0-1 x 5 days (amox
+clavulanic acid)
T.N:-T Moxiforce-CV or Mega-CV
625,Novaclav 625 , kid tab-228.Dose:
20 mg/kg/dose BD
Indications:for RTI , UTI, dental, skin
and soft tissue infections, intra
abdominal and
gynaecological sepsis, cat
scratches,infected animal/human
bites).
4.C Novaclox 1-1-1 x 5 days
(amoxicillin
+dicloxacillin)(dramaclox)(ped tab
available)
5.C Megapen 1-1-1-1 x 5 days
(ampicillin +cloxacillin)(kid tab
available)
6.C Aldinir or Zefdinir 300mg 1-0-1 x
5 days (cefdinir)(very expensive)
Indications:pneumonia,a/c
exacerbations of c/c bronchitis,
Ent ,skin)
7.C Phexin/ sporidex 500mg 1-1-1-1
x 5 days (cephalexin)
Indications:For bone and joint
infections, pharyngitis, skin and soft
tissue,tonsillitis, UTI
8.T Azithral or Azee 500mg 1-0-0 x 3
days 1hr before food(azithromycin)
(specific for respiratory
infections)(also for skin,STD’s, PID,
urethritis, cervicitis)
9 T Roxid 150mg 1-0-1 x 5 days 30
min before food (roxithomycin)
(for RTI, ENT, skin & soft tissue,
genital tract infections)
10.T Droxyl 500mg 1-0-1 x 5 days
(cefadroxil);Syp (125 /5 or 250/5)
available
(30 mg/kg/day in 2 div doses)(strep
throat infections, UTI,skin)
11.T Taxim-O/ topcef
50/100/200mg(DT tab available)
1-0-1 x 5 days (cefixime)
(resp, urinary, biliary infections)
12.T Ceftas-AL1-0-1 x 5 days
(cefixime+ambroxol+lactobacillus
spores)
13.T Ciplox 500mg(100/250/750)
1-0-1 x 5 days (ciprofloxacin)(for
UTI,bone,soft tissue,
gynaecological,wound infection,
Bact gastroenteritis, Respiratory)(all
other FQ’s C/I in children)
14.T Norflox 400mg 1-0-1 x 5 days
(norfloxacin)( for UTI & GIT problems)
(advise to drink more
water).Best , if taken empty stomach
with water, don’t take with diary
products
15.T Oflox /Zenflox 200mg 1-0-1 x 5
days (ofloxacin)(c/c bronchitis, other
respiratory, ENT)
16.T Levobact or Levoday or Loxof
500mg 1-0-0 x 5 days (levofloxacin)
(advise to drink more water)
17.T Septran/Bactrim d.s. 1-0-1 x 5
days (sulfamethoxazole 800
+trimethoprim 160)
(advise to drink more water) Syp
available( 200 + 40)/5 ml
18.T Proflox 400mg 1-0-1 x 5 days
(pefloxacin) ( for UTI & GIT
problems)
19.T
Cepodem/Monocef-o/podocef/mac
pod 100/200mg 1-0-1x 5
days(cefpodoxime)
(for RTI, UTI, skin and soft tissue).
20.T Klox (cloxacillin) 250/500 mg
tds/Qid(furuncle, abscess, carbuncle,
impetigo, osteomyelitis,
bites), syp (125 /5)
(100-200mg/kg/day in 4 divided
doses)
21.T clarithro/claribid/synclar
(clarithromycin) 250/500 mg
1-0-1(resp, skin & soft tissue)
22.T Altacef 250/500
1-0-1(cefuroxime)(URI, LRI, UTI)
For children and infants most
pediatric medicines are available in
syrup/Drops.
1-3 yrs =1/2 tsp tds; 3-6 yrs =1 tsp
tds; 6-10 yrs =2 tsp tds or 1/2 adult
tabs.
This can be used as a rough
guideline to prescribe common
pediatric medicines. The dose should
be adjusted according to the built
and weight.
Commonly used antibiotics in
children
1.Syp Amoxicillin (125 /5 or 250/5)
[T N:- mox,Novamox](DT 125, 250
mg available)
Dose: 30-50 mg/kg daily in divided
doses Q8H or Q12H. In Practice 15
mg/kg/dose Q8H
Novamox Dps (100 /1) available
Syp Augmentin/Mox CV 228 /5, 156
/5, 312 /5 available,(Amoxicillin +
clavulanic acid) Novamox
CV/Mox CV dps,each 1 ml contain
amox=80 mg,clavulanic acid=11.4
mg. Augmentin/ Mox
CV Syp 457 (400 + 57)/5ml, 156(125
+ 31)/5ml, 228(200+28)/5ml,
312(250 +62) available.
2.Syp Ampicillin(125 /5 or 250/5)
Dose is 50-100 mg/kg/daily in
divided doses Q6H
3.Syp Azithromycin(100 /5 or 200/5)
{T N:- azee, ATM}(Dose for children
above 6 months-10
mg/kg/day for 5 days)
4.Syp Cefixime (50 /5 or 100 /5 ) {T
N:- taxim-o,topcef}(8 mg/kg/day in
divided doses Q12H),
Dps 25/1 available
5.Syp Septran (sulfamethoxazole
200+ trimethoprim 40)(6-10
mg/kg/24 hr(TMP) div into 2
PO)(dose calculated in terms of mg
of TMP).Paed tablets: (100+20)
6.Syp Ampoxin Or Syp
Roscilox(ampicillin +cloxacillin)
7.Syp Synclar/Maclar(125
/5)(clarithromycin)(15 mg/kg/day in
2 divided doses)
(URTI,LRTI,sinusitis,otitis media
etc)(125 DT available)
8.Syp Kefpod/Macpod(50 /5 or
100/5)( cefpodoxime)(10 mg/kg/day
div into 2 doses PO)
(LRTI,URTI)
9.Syp Phexin(cephalexin)(125 /5 or
250/5) (50-100 mg/kg day in 3 or 4
doses PO)(DT 125, 250 mg
available). Phexin Dps 100 /1
available.
10.Syp Altacef (cefuroxime)(125
/5)(30 mg/kg/day div into 2-3)
For pregnant ladies
Amoxicillin,cephalosporins,
ampicillin & cloxacillin
combination,amoxicillin &
clavulanate combination,
Penicillin G. Azithromycin(class B)
Antipyretics
Note:- In Children, if fever is
accompanied by rashes,esp vesicular
or maculo papular suspect
Chickenpox or Measles respectively.
In measles, the child is usually sick
looking with, rashes
starting from face.
1.T Calpol/Panadol/Dolo
500mg/650mg 1-1-1-1 x 3
days( p’mol or acetaminophen)
2.T Ibugesic or brufen
200/400/600mg 1-0-1 x 3
days(ibuprofen)
3.T Meftal or ponstan 250mg/500
1-1-1x3 days(mefenamic acid)(ideal
for dental pain)
4.T Pirox /Dolonex 20mg 1-0-0 x 3
days(piroxicam)
5.T Ibugesic Plus 1-0-1 ( ibuprofen+
P’mol)
6.T Meftal forte/ meftagesic(Meftal
500 + P/L 450)
For children
1.Syp P’mol(125 /5 or 250/5)(10-15
mg/kg/dose x 4 times)(C/I in less
than 2 kg)
T N:-
Calpol,crocin,dolo,febrinil,febrex
etc.(Calpol,
Dolo,Babygesic,Crocin,Febrinil dps
available)
Nopain dps(15 ml) (100 /1) available,
Tab 125 available
2.Syp Ibuprofen(100 /5)(8-10
mg/kg/dose x 3 times)(may
precipitate aspirin induced asthma,
so
don’t give to asthmatic or dyspnoeic
pts).Syp ibugesic plus(ibuprofen 100
+ P/L 162.5 /5 ml)
Another formula: dose in ml= wt / 2
3.Syp Meftal(50/5 or 100/5)
(generally not used < 6 months)(8
mg/kg/dose x 3 times a day)
(DT-Tab 100 available); ( wt x 4/10 =
dose in ml, applicable only for 100/5
formulation)
Syp Meftagesic(P/L 125 mg,
mefenamic acid 50mg/5 ml)
For pregnant ladies
P ‘mol only