Things We Do For No Reason™: Treatment of Infection-Related Fever in Hospitalized Patients

The hospitalist admitted a 56-year-old man with hypertension and hyperlipidemia to the general medical unit for community-­acquired pneumonia and started him on appropriate antimicrobial therapy. On the evening of admission, the nurse woke the patient to take his vital signs and noted a fever of 39.1°C (102.4°F). The patient had a pulse of 90 beats per minute, normal blood pressure, and a stable supplemental oxygen requirement via nasal cannula. The nurse noted an oral acetaminophen “as needed” order for fever. She woke the patient again to administer acetaminophen and notified the hospitalist.

Hospitalists frequently encounter febrile patients. According to one large hospital survey, fever occurs in 25% of pediatric and 31% of adult medical patients.¹ Fever in hospitalized patients most commonly results from infection, but autoimmune disease, malignancy, and an array of other inflammatory conditions cause fevers as well.¹

Defined as an elevated body temperature resulting from a raised hypothalamic set point², hospitalists often treat fever with acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs). These routinely administered medications act centrally to temporarily lower the hypothalamic set point and relieve fever.^2,3 Standard hospital admission order sets commonly include an as-needed antipyretic every 4 to 6 hours for treatment of fever, regardless of the presence of fever-related symptoms.

Fever is differentiated from hyperthermia, where temperature increases because of dysregulated peripheral processes despite a normal hypothalamic set point.² Examples of hyperthermia include heat stroke, malignant hyperthermia, and neuroleptic malignant syndrome. Notably, antipyretic medications have no effect on hyperthermia, but physical means, such as cooling blankets, can lead to temperature reduction.²

Hospitalists prescribe antipyretic medication to alleviate fever-­related symptoms, including headache, chills and sweats, and joint and muscle aches.³ While researchers have sparingly studied this practice, available evidence and experience suggest that fever-related symptoms decline in parallel with defervescence after administration of acetaminophen or NSAIDs in both adult and pediatric populations.^4,5 One randomized, controlled, double-blind study of nearly 400 adult outpatients in Germany with febrile upper respiratory tract infections showed that both aspirin and acetaminophen bested the placebo in reducing fever and associated headache, achiness, and discomfort over a span of 6 hours.⁴ In another study, this time with pediatric patients hospitalized with fever and uncomplicated respiratory tract infections, patients who received acetaminophen had statistically significant improvements in activity, alertness, mood, comfort, appetite, and fluid intake 6 hours after receiving that therapy.⁵