Fever Clinical Pathway — All Settings

International Travel
Fever ≥ 38.5°C without a source in a traveler within 30 days of return to the U.S.
Evaluate Traveler Risk The following link provides specific location of travel and information about endemic disease and recent disease outbreaks: http://wwwnc.cdc.gov/travel/notices  
The following chart provides endemic diseases from common travel areas.
Geographic Area Common Tropical Diseases Causing Fever Other Infections Causing Outbreaks/Clusters in Travelers
Caribbean Dengue, malaria (Haiti) Acute histoplasmosis, leptospirosis, chikungunya, Zika
Central America Dengue, malaria (primarily P vivax.) Leptospirosis, histoplasmosis, coccidioidomycosis, Zika
South America Dengue, malaria (primarily P vivax.) Bartonellosis, leptospirosis, typhoid, histoplasmosis, Zika
South-central Asia Dengue, typhoid, malaria (primarily non-falciparum) Chikungunya
Southeast Asia Dengue, typhoid, malaria (primarily non-falciparum) Chikungunya, leptospirosis
Middle East Typhoid, hepatitis (some areas with malaria, dengue) MERS, meningococcal meningitis (Hajj/Umrah Pilgrimage)
Sub-Saharan Africa Malaria (esp. falciparum), tickborne rickettsiae, acute schistosomiasis, filariasis African trypanosomiasis, chikungunya, typhoid, filariasis, Ebola
CDC Yellowbook: Fever in Returned Travelers  
  1. Patient preventative measures and compliance to them, including:
    • Vaccinations
    • Medications
  2. Unusual exposures during travel:
    • Animal bites including rodents
    • Food/water source including dairy
    • Swimming in fresh water
    • High-risk sexual activity
    • Tattoos/injections
    • Sick contacts with specific known diseases especially tuberculosis or measles
Infection Precautions
  • Contact Infection Prevention & Control:
    • IP&C Office 4-2096 or pager 77745 for any precaution/isolation concerns
  • Consider need for additional isolation precautions, based on history and clinical symptoms, if not already in place by triage job aid
  • Specific Considerations for suspected or confirmed diagnosis of key pathogens:
    • Diseases and Precautions
    Disease Precautions
    Typhoid Contact precautions
    MERS* Negative pressure room, expanded precautions
    Ebola/hemorrhagic fever* Full PPE with IP&C guidance
    Measles*, tuberculosis Negative pressure room, airborne precautions with N95 mask
    • *Contact IP&C with any suspected case
    • The other diagnoses listed do not specifically require additional precautions
Laboratory and Diagnostic Testing
  • Testing as indicated by patient’s clinical picture after head-to-toe exam and per ED physician’s assessment (e.g., UA if dysuria, monospot if lymphadenopathy, CXR if hypoxic) and evaluation for the usual causes of fever in a child
  • Recommended testing for all patients in addition to targeted diseases identified by links above and usual fever workup:
    • CBC w/diff
    • Comprehensive metabolic panel
    • Blood culture (esp. if any concern for typhoid)
    • “Blood parasite” test for malaria if patient travel to endemic area
    • Stool culture (typhoid, E. coli)
    • Urinalysis
  • Additional Testing to Consider
    • Chest X-ray
    • Monospot/EBV titers
    • HIV (esp. acute seroconversion illness)
    • PT/INR, PTT if concern for sepsis/DIC/hemorrhagic fever
    • LP if change in mental status (trypanosomes, arboviruses)
    • Other testing as per patient’s identified risk factors (e.g., Schistosomiasis testing if swam in fresh water, etc.)
  • Further concern by specific tropical disease
    • ID consultation available for any clinical patient recommendations (pager 10467)
Disposition Criteria for Febrile Returned Traveler
  • Discharge Criteria for Febrile Returned Traveler
    • No concern for highly communicable disease of public health importance (e.g., measles, Ebola)
    • Normal/reassuring VS and labs AND
    • Nontoxic appearing/able to self-hydrate AND
    • Low suspicion for malaria IF
    • Follow-up in 24 hours is possible
  • Discharge Instructions
    1. PMD follow-up in 24 hours
    2. If in dengue-endemic area/concern for dengue patient should have daily CBC by PMD (if possible) until afebrile x > 48 hours to look for subtle signs of plasma leakage/developing dengue hemorrhagic fever (DHF):
      1. Hemoconcentration as defined by > 20% increase in hematocrit (above average for age or compared to the previous day) or
      2. > 20% post-volume drop in hematocrit if received IV fluids
      3. Thrombocytopenia (< 100 K)
    3. Infectious Diseases outpatient follow-up as needed
  • Requires Admission
    • Any concerning lab value
    • Abnormal vital signs, worrisome clinical exam, or inability to self-hydrate
    • High suspicion for malaria — patient should be admitted for diagnosis and clinical observation
    • Anyone meeting criteria for dengue hemorrhagic fever or in shock
    • As per IP&C or Dept. of Public Health if concern for highly communicable disease of public health importance