What are the recommended management strategies for a patient with PUO who has no clear diagnosis after initial investigations?

Recommended management strategies for a patient with pyrexia of unknown origin (PUO) after initial investigations show no clear diagnosis include:

• Consider a period of observation in hospital to help differentiate between non-serious and serious illness, especially if the patient is a child aged 3 months or older, as this may allow further clinical assessment and monitoring for deterioration.

• Provide safety-netting advice if the patient is not admitted, including verbal and/or written information on warning symptoms and how to access further healthcare promptly.

• Arrange further follow-up at a specified time and place to reassess the patient and monitor the clinical course.

• Liaise with other healthcare professionals, including out-of-hours providers, to ensure direct access for the patient if further assessment is required.

• Consider social and family circumstances, parental anxiety, recent travel history, and any contacts with serious infectious diseases when deciding on admission or further management.

• In children, if no features of serious illness are present (the 'green' group), they can be cared for at home with appropriate advice on when to seek further medical attention.

These strategies aim to balance the need for safety and timely diagnosis with avoiding unnecessary investigations or hospital admissions when the cause of fever remains unclear after initial assessment.

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