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Fever & Sepsis

Find the source; respect the host’s risk.

LearnQuick referenceClinical practice

Your objective: explain the approach, recognize important warning signs, then test your recall.

Abbreviations explained
ACS
Acute coronary syndrome
OMI
Occlusion myocardial infarction
ECG
Electrocardiogram
PE
Pulmonary embolism
POCUS
Point-of-care ultrasound
QTc
QT interval corrected for heart rate
LBBB
Left bundle branch block
RBBB
Right bundle branch block
hs-cTn
High-sensitivity cardiac troponin
CTA
Computed tomography angiography
ICU
Intensive care unit
Filter

The jobFind the source; respect the host’s risk.

  1. Screen with NEWS2, MEWS, or SIRS — not qSOFA alone.
  2. Host first: age, neutropenia, devices, pregnancy, travel.
  3. Shock or probable sepsis: antibiotics within 1 hour. Possible sepsis without shock: rapid look, then within 3 hours if infection remains likely.
  4. Start crystalloid resuscitation, then use dynamic reassessment to individualize further fluid; start norepinephrine if MAP remains low during resuscitation (SSC).

Fever evaluation is host-dependent: age, immunosuppression, devices, pregnancy, and travel define the danger list.

Screen for sepsis with a sensitive tool (NEWS2, MEWS, or SIRS — not qSOFA alone). Treat shock immediately; possible sepsis without shock gets a rapid workup and antibiotics within 3 hours if infection remains likely.

Sepsis / septic shock Critical

Key: Hypotension, tachypnea, altered mentation, lactate >2. Antibiotics within 1 h for shock or probable sepsis; within 3 h for possible sepsis without shock after a rapid look. Use balanced crystalloid for initial resuscitation and dynamic measures to guide further fluid. Begin norepinephrine if MAP remains low during resuscitation (SSC 2026).

Necrotizing soft-tissue infection / toxic shock Critical

Key: Pain out of proportion, rapid spread, crepitus, or shock with a wound/soft-tissue source — surgery now, not a wait-for-CT strategy.

Neutropenic fever Critical

Key: ANC <500 + a single temperature ≥38.3°C (or ≥38.0°C for 1 h) — immediate empiric antipseudomonal antibiotics. MASCC/CISNE may identify low-risk outpatient candidates.

Bacterial meningitis Critical

Key: Fever + meningismus/altered mentation — first dose of antibiotics (and dexamethasone if pneumococcal likely) must not wait on CT.

Infective endocarditis Critical

Key: Fever + new murmur, IVDU, embolic signs — blood cultures ×3, echo.

Malaria / travel sepsis Critical

Key: Any fever returning from an endemic area = malaria until proven otherwise (thick/thin smear ± RDT, repeated if negative).

Ectopic pregnancy / puerperal sepsis Critical

Key: Fever in pregnancy or within 6 weeks postpartum — obstetric pathway.

URIs, gastroenteritis, pharyngitis, UTI Common

Key: Self-limited or outpatient-managed; keep criteria strict.

Tick what your patient has — the banner updates as you go.

Temperature course and home antipyretics

Host factors

age >65, chemotherapy, steroids/biologics, HIV, asplenia, devices (lines, valves, shunts), pregnancy

Travel, exposures, TB contacts

Localizing symptoms

cough, dysuria, rash, diarrhea, headache, joints

Recent procedures, wounds, dental work

Full vitals including RR and mentation; use NEWS2/MEWS/SIRS — qSOFA is specific but too insensitive to screen alone (SSC 2021 and 2026)

Rash

petechial/purpuric (meningococcemia), target (Lyme), drug eruptions

Line and wound sites; murmurs; costovertebral and joint exam

Meningeal signs; fundoscopy; abdominal/pelvic exam as indicated

Bedside

  • Glucose, lactate, pregnancy test when appropriate
  • POCUS: effusions, hydronephrosis, cardiac function

Labs

  • CBC with differential, cultures before antibiotics when it will not delay them
  • Urine studies and CXR per focus; malaria smear if travel; LP if CNS suspicion
  • Inflammatory markers (CRP/procalcitonin) as institutional adjuncts — they do not rule out sepsis

Imaging

  • CXR; CT for occult source (intra-abdominal abscess) when unclear
Medication safety reminder

Use this as a first-pass prompt; verify all medications, doses, concentrations, contraindications, weight, pregnancy status, and local protocols before administration.

Check indication, allergy, route, renal/hepatic risk, interactions, monitoring, and local formulary.

Discharge

  • Benign source, normal vitals and mentation, reliable follow-up with clear return precautions (uncomplicated viral illness). Selected low-risk neutropenic fever (MASCC) per protocol.

Admit

  • Sepsis without shock, comorbidity burden, uncertain source needing IV therapy, social/safety concerns.

ICU

  • Septic shock, unstable neutropenic sepsis, deteriorating meningitis, multi-organ dysfunction.

Use objective reassessment and the local pathway.

Before the next decision · reassess and hand over

Use these learning prompts with the presentation’s pathway. They are not discharge criteria.

  1. Reassess: compare symptoms, observations and examination with the initial assessment and response to treatment.
  2. Warning signs for Fever & Sepsis:
    • Hypotension, tachypnea, or altered mentation
    • Lactate ≥2 mmol/L or fluid-unresponsive hypotension
    • Neutropenia, asplenia, recent chemotherapy
    • Fever + new murmur or IVDU
    • Purpuric rash or severe headache
    • Fever in pregnancy or within 6 weeks postpartum
    • Return from a malaria-endemic region
  3. Reconsider: check unresolved findings and alternative explanations, including the pitfalls below.
  4. Escalate: communicate deterioration, uncertainty or needs beyond the current setting.
  5. Plan the transition: identify outstanding results, responsibility for follow-up, patient understanding and specific return advice.
Review this presentation’s disposition pathway →Practice a handover →

Clinical Pearls

  • Do not screen with qSOFA alone — NEWS2, MEWS, or SIRS are more sensitive (SSC).
  • Antibiotics within 1 h for shock or probable sepsis; within 3 h for possible sepsis without shock after a rapid look.
  • Use balanced crystalloid initially, then dynamic reassessment and norepinephrine when MAP remains low.
  • Afebrile does not mean not septic — especially the elderly and immunosuppressed.

Pitfalls

  • Afebrile ≠ not septic — elderly, immunosuppressed, and antipyretic-treated patients may never spike.
  • Do not use qSOFA as the sole screening tool (SSC strong recommendation). NEWS2/MEWS/SIRS are more sensitive.
  • Antibiotics within 1 h for septic shock and for probable sepsis; possible sepsis without shock allows a rapid evaluation and antibiotics within 3 h if infection remains likely.
  • Do not continue giving fluid without reassessment — use dynamic measures, perfusion, and the patient’s current condition to guide further resuscitation.
  • Neutropenic patients lack pus and peritoneal signs.
  • Asplenic + fever = an emergency (encapsulated organisms).
  • Line infections hide inside “no obvious source” sepsis.
  • Necrotizing infection looks like “cellulitis” until the patient is in shock — pain out of proportion is the tell.
PRACTICE REFRESHER

Rapid recall

Test your first action and the dangerous diagnoses before revealing the answer.

01 · First move

Before you scroll, what needs to happen first?

02 · Immediate threats

Name at least two diagnoses that cannot wait.

PRIVATE TO THIS DEVICE

Your learning note

Capture a weak point, a teaching pearl, or a question to take to your next shift.

Review schedule starts when marked reviewed
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Selected guidance · source check 2026-09-07. These 1 source links support selected teaching points, not a complete review of this topic. Check population, setting and local protocol before applying a recommendation.

  • Rosen’s Emergency Medicine, 10th ed. (2023) — fever & sepsis
  • Surviving Sepsis Campaign 2021; SSC 2026 update (NEWS/MEWS/SIRS over qSOFA; antibiotic timing stratified by shock)
  • IDSA: neutropenic fever, bacterial meningitis, asymptomatic bacteriuria
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