You give me fever

Consider your next patient-- a previously healthy 35-year-old female presenting with fever... and a recent travel history. How does this change your management and workup? Behold: an algorithmic approach to fever in the traveler.

Step 1: Sequester the spreaders. Do they have diarrhea? That could be typhoid or cholera or simple ETEC, spread by a fecal-oral route. Place them in contact precautions. Cough? Droplet precautions is a safe bet, unless they need something more aggressive. If they've traveled to Saudi Arabia or Oman within the past 2 weeks they are at risk for MERS corona virus and need airborne precautions. Do they have fever plus a rash? Or are they bleeding from anywhere? Ebola is still happening in the DRC! A history of fever and travel to an ebola-affected region within 3 weeks militates what I like to call "extreme contact" precautions--bunny suit, airborne isolation and all. Have they had healthcare exposure while abroad? Rates of ESBL and CRE are sky high in certain locations. Place them under contact precautions and consider rectal swab for colonization to protect your other domestic patients.

Step 2: Treat the sick. 34% of fevers in travelers are caused by the fancifully named "cosmopolitan infections" like urinary tract infections, influenza, and meningitis. If a patient looks septic, treat them for sepsis. This means lactate begets lactate, blood cultures before antibiotics, fluids for hypotension, and early antibiotics. broad spectrum antibiotics will treat many of your exotic fevers as well as your domestic workhorses--typhoid can be treated with ceftriaxone, melioidosis improves with ceftazadime or a carbapenem, ETEC improves with fluoroquinolones. While treating, consider the causes of exotic fever that end in fatality. Many of these, such as dengue or hepatitis A, will improve with appropriate supportive therapy, but 75% of life-threatening exotic fevers are caused by malaria falciparum and require treatment with a quinidine or artemisin-based IV therapy.

Step 3: Have an awesome mnemonic for a good travel history. Try 'THE 4 Ws and the H"

Where did you go?

When were you there? When did your fever start? Incubation periods are king here. Ebola has a 3 week incubation period. 98% of malaria presents within 3 months.

Who were you exposed to? Who did you expose? Keep in mind that your patient may have exposed very young, very old, and immunocompromised future patients.

What did you do there? Did you eat street food? Did you swim in water? Did you have sex? Were you hospitalized?

How did you protect yourself? Did you take travel vaccinations? Malaria prophylaxis? Any OTC antibiotics while you were out there? And since having a fever, have you been seen anywhere else? Blood cultures may be positive at an outside hospital and clinch the diagnosis.

This, of course, does not supplant an infectious disease or global health fellowship. But it does give you the tools you need to answer your specialist's questions once you get him or her on the phone. And if an infectious disease specialist is unavailable, there are websites that can stand in in a pinch:

PROMEDMAIL.ORG

Updated list of global outbreaks, searchable by disease and country. You can search by location or disease. Particularly good for keeping you up at night in fear of the next pandemic.

CDC.GOV/TRAVEL/DESTINATIONS/LIST

Gold standard for updated infectious risks by destination. Excellent for both prophylaxis if you are traveling yourself and diagnosis if you are taking care of a febrile patient.

FEVERTRAVEL.CH

Swiss website that runs you through a list of countries, dates, exposures, and symptoms, and makes recommendations for workup. Caution: Does not help if your patient is septic and needs treatment. Recommends "admission" for these patients.

If you prefer paper or would like to read in more detail, below are two excellent and recent review articles worth printing and reading at your leisure or saving to your external hard drive for your quick reference. They have excellent infographics and are easily digestible:

Thwaites GE, Day NP. Approach to Fever in the Returning Traveler. N Engl J Med. 2017 Feb 9;376(6):548-560.

Fink D, Wani RS, Johnston V. Fever in the returning traveller. BMJ. 2018 Jan 25;360.

And other references:

•Boggild AK, Esposito DH, Kozarsky PE, et al. Differential diagnosis of illness in travelers arriving from Sierra Leone, Liberia, or Guinea: a cross-sectional study from the GeoSentinel Surveillance Net- work. Ann Intern Med 2015;162:757-64

•Bottieau E, Clerinx J, Schrooten W, et al. Etiology and outcome of fever after a stay in the tropics. Arch Intern Med 2006; 166:1642-8.

•Griffith KS, Lewis LS, Mali S, Parise ME. Treatment of malaria in the United States: a systematic review. JAMA 2007; 297(20):2264-77.

• Haydar S, Spanier M, Weems P, Wood S, Strout T. Comparison of qSOFA score and SIRS criteria as screening mechanisms for emergency department sepsis. Am J Emerg Med. 2017 Jul 6. pii: S0735-6757(17)30509-0.

•Marik PE, Taeb AM. SIRS, qSOFA and new sepsis definition. J Thorac Dis 2017;9(4):943-945.

•Nusbaum J, Gupta N. Recognizing and Managing Emerging Infectious Disease in the Emergency Department. EB Medicine. May 2018.

•Taylor SM et a. Does this patient have Malaria? JAMA 304(18):2048, November 10, 2010.

•Wichmann O, et al. Severe Dengue Virus Infection in Travelers: Risk factors and Laboratory Indicators. J Infect Dis 195:1089, April 15, 2007.


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