AIIMS guidance on management of Acute Febrile Illness

All India Institute of Medical Sciences, Delhi has released AIIMS Antibiotics Policy which has been prepared by the Department of Medicine with Multidisciplinary collaboration. The guidance for Febrile illness and Sepsis includes guidance on Acute Febrile Illness the salient features of which are hereunder.

Acute Febrile Illness (AFI): Refers to patients presenting with acute onset fever ( >= 38.3'C or >=101'F) lasting for more than 2 days but usually less than 14 days, with no definitive localising symptoms or signs.

Patients presenting with AFI should be assessed for organ dysfunction at presentation and symptoms/signs suggestive of sepsis should be ruled out as management protocol will differ.

Most common causes of AFI have been covered below with their specific treatment options.

Note: Patients presenting with AFI (> 2 days duration) should undergo a baseline investigation (CBC/ESR/Peripheral smear/LFT/etc) as deemed necessary by the treating physician, apart from the usual screen for common causes of tropical fever (discussed below).

All patients with organ dysfunction should be managed inpatient.

A) AFI (RDT- positive for P. falciparum)

-2 RDTs 12 hour apart (if 1st RDT is negative) should be done for malaria.

-Send Peripheral smear and QBC for malaria

Severe Malaria: Injection Artesunate 2.4 mg/kg IV at 0, 12, 24, 48 hours

Continue once daily till the patient is not able to accept orally

Should be followed by oral ACT therapy

Non-Severe Malaria: Oral ACT (Artemether/ Lumefantrine 80/480 1tab BD) for 3 days

Radical cure: Primaquine 0.75 mg/kg single dose after ruling out G6PD deficiency

B) AFI (RDT positive for P. Vivax)

Severe Malaria: Injection Artesunate 2.4 mg/kg IV at 0, 12, 24, 48 hours

Continue once daily till the patient is not able to accept orally

Should be followed by oral therapy

Non-severe Malaria: Chloroquine (500 mg tablet = 300 mg base)- 2 tablets stat, 1 tablet in six hours, 1 tablet once daily for two days

Radical cure: Primaquine 0.25 mg/kg OD for 14 days after ruling out G6PD deficiency

C) AFI (RDT negative)- Dengue or Chikungunya serology positive

No antibiotics needed

Remarks:

<5 days of fever – send NS 1 antigen for Dengue

>5 days of fever send IgM ELISA for Dengue and Chikungunya

D) Scrub typhus:

IFA/ ELISA for scrub typhus (>3 days of fever) for diagnosis

Treatment: Tab/Inj doxycycline 100mg BD 7-10 days Or

Tab/Inj azithromycin 500mg od x 5 days

Note: Defervescence of fever with doxycycline takes only 48-72 hours.

E) Enteric fever

Widal may be useful for diagnosis only after the 1st week of fever, however, results need to be interpreted with caution.

Treatment:

Tablet Cefixime 400mg BD X 10-14 days Or

Tablet Azithromycin 1g/day x 5 days Or

Tablet Azithromycin 1g stat followed by 500mg/day for 6 days Or

Ceftriaxone 1-2 g IV BD x 10-14 days

Note: Defervescence of fever takes around 4-7 days with ceftriaxone. Consider replacing or adding azithromycin to ceftriaxone only after 4-7 days.

F) Leptospirosis:

Treatment:

Tablet Doxycycline 100 mg BD x 7 days, Or

Inj Ceftriaxone 1-2 g IV BD x 7 days

G) Undifferentiated fever/ Fever with no localisation- Dengue or Chikungunya or Scrub or other serology negatives/ awaited/ cannot be done or Blood cultures awaited:

Inpatient management:

Treatment: Start with Injection Ceftriaxone 1-2 g IV BD plus Injection /oral doxycycline 100mg BD or Start with Azithromycin 1g OD

Outpatient management:

If clinical condition permits, to wait until the availability of reports.

If strong clinical suspicion of bacterial infection is present, and treatment needs to be initiated:

Treatment: Tab Cefixime 200mg BD x 5-7 days or Azithromycin 500 OD for 5 days

Note: - Send blood culture before starting antibiotics in all patients

- De-escalate based on specific results