A protocol for the emergency department management of acute undifferentiated febrile illness in India
© Thangarasu et al; licensee Springer. 2011
Received: 5 May 2011
Accepted: 5 September 2011
Published: 5 September 2011
Fever is a common presenting complaint in the developing world, but there is a paucity of literature to guide investigation and treatment of the adult patient presenting with fever and no localizing symptoms.
The objective of this study was to devise a standardized protocol for the evaluation and treatment of febrile adult patients who have no localizing symptoms in order to reduce unnecessary testing and inappropriate antimicrobial use. After devising the protocol, a pilot study was performed to assess its feasibility in the emergency department.
A protocol was formulated for adult patients presenting with fever who had no clinical evidence of sepsis and no localizing symptoms to suggest the etiology of their fever. Investigations were based on duration of fever with no investigations indicated prior to day 3. Treatment was guided by results of investigations. A pilot study was performed after protocol implementation, wherein data were collected on successive adult patients presenting with fever.
During the 6-week study period, 342 patients presented with fever, 209 of whom fit the parameters of the protocol, with 113 of these patients presenting on the 1st or 2nd day of fever. All patients experienced defervescence of fever, with ten patients being lost to follow-up. Of the patients presenting on day 1 or 2 of fever, 75.2% (85/113) defervesced without the need for testing; 53.1% (60/113) experienced defervescence without the need for antimicrobial therapy.
Implementation of this rational, standardized protocol for the assessment and treatment of stable adult patients presenting with acute undifferentiated febrile illness can lead to reduced rates of testing and antimicrobial use. A prospective, controlled trial will be required to confirm these findings and to assess additional safety outcome measures.
Fever is a common presenting complaint in the developing world and is the most common presentation to the Emergency Department (ED) at our institution, Sundaram Medical Foundation (SMF) in Chennai, India . Febrile illness can be localized to organ systems or non-localized, commonly referred to as acute undifferentiated febrile illness (AUFI). In the Western world, AUFI is often due to self-limited viral conditions. However, in the developing world, the differential diagnosis for AUFI includes potentially significant illnesses such as malaria, dengue fever, enteric fever, leptospirosis, rickettsiosis, hantavirus, and Japanese encephalitis [2–10]. There is a paucity of literature on the appropriate evaluation of adult fever patients without localizing symptoms in the ED . In the absence of established protocols, patients may be subjected to unnecessary investigations at considerable cost and the inappropriate prescribing of antimicrobial therapy [12, 13]. In the following, we describe a protocol that was formulated and implemented in the SMF ED to evaluate adult patients presenting with non-localizing fever.
The aim of this pilot study was to devise and implement a protocol for the management of stable adult patients presenting to the emergency department with fever as their chief complaint and no localizing symptoms. The overarching goal of the protocol was to standardize the approach to such patients in a way that reduced unnecessary testing and inappropriate use of antibiotics. Additional goals, such as improving time to fever resolution, reduction in hospital admission rate, and reduction in mortality, while also ultimately desirable, were not assessed in this study.
In order to assess the feasibility of the implementation of this protocol, data were prospectively collected on all eligible patients presenting to the SMF ED between 1 August 2008 and 15 September 2008. Data collected included day of fever at presentation, day of fever resolution, investigations performed, antimicrobial therapy received or not, and final diagnosis. Thirty-day follow-up was performed by phone interview and examination of medical records to assess final outcomes. The study protocol was reviewed and approved by the IRB at Sundaram Medical Foundation.
Outcomes of stable adult patients with acute undifferentiated febrile illness presenting on day 1 or 2 of fever
Eligible patients, day 1 or 2 of fever
Received investigations initially
Did not receive investigations initially
Defervesced without need for investigations
Eventually investigated as per protocol
Lost to follow-up
Total defervesced without need for investigations
Received antimicrobials initially
Did not receive antimicrobials initially
Defervesced without need for antimicrobials
Eventually required antimicrobials
Lost to follow-up
Total defervesced without need for antimicrobials
Antimicrobial therapy was prescribed to 35 of the 113 AUFI patients who initially presented within the first 2 days of fever and ultimately received at a later date by 15 additional patients. Three patients were lost to follow-up. Of the patients, 53.1% (60/113) experienced defervescence without the need for antimicrobial therapy.
Given the relative frequency with which emergency physicians in India encounter patients with acute undifferentiated febrile illness, it is in our interest to develop a standardized approach to evaluating these patients. Evidence-based protocols have been shown to be cost-effective  and improve mortality  in the emergency department setting. This protocol has the more modest goals of reducing costs, avoiding unnecessary testing and inappropriate therapies, and reducing antibiotic resistance and rates of misdiagnosis. We have described a protocol that represents a rational, graded approach to stable adult patients with AUFI that is informed by local infectious epidemiology . In this pilot study, investigations were or could have been avoided in 75.2% of patients, and antimicrobial therapy was unnecessary for fever resolution in 53.1% of eligible patients with fever of < 3 days duration. These data suggest that this protocol has the potential to reduce unnecessary testing and inappropriate antimicrobial use. A prospective trial will need to be carried out both to corroborate these findings as well as to investigate the ability of the protocol to influence additional outcome measures such as time to fever resolution, hospital admission rate, and mortality rate.
Implementation of a rational, standardized protocol for the assessment of stable adult patients with acute undifferentiated febrile illness in this south Indian emergency department demonstrates a potential to lower rates of unnecessary testing and antimicrobial use. The protocol will need to be prospectively validated in a controlled fashion in order to confirm these findings as well as to assess its safety.
TS is a Resident Physician in Internal Medicine, University of Pittsburgh Medical Center-Mercy Hospital. NP is Senior House Officer in Emergency Medicine at Sundaram Medical Foundation. PVR is Head of Department, Department of Emergency Medicine at Sundaram Medical Foundation. AR is Medical Director and Head of Department, Department of Surgery at Sundaram Medical Foundation. JSD is International Emergency Medicine Fellow at Long Island Jewish Medical Center.
List of abbreviations
Sundaram Medical Foundation, Chennai, Tamil Nadu, India
acute undifferentiated febrile illness
institutional review board.
We thank Dr. D.V. Nagendra Naidu, who helped with the initial design of the study; we thank Drs. T. Girija, V. Seshadri, and M. Swamikannu, who were involved in the protocol design.
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