Newly updated guidelines from IDSA and the American College of
Critical Care Medicine are intended to help ICU physicians evaluate a
new fever in their patients and determine whether infection is present
so that additional testing can be avoided and therapeutic decisions can
be made. The guidelines also offer a helpful background check for
infectious diseases physicians who do consults in the ICU.
In some ICUs a new fever in a critically ill patient can trigger
automatic orders for many time-consuming, costly, disruptive tests. The
patient may experience discomfort, be exposed to unneeded radiation,
have to be transported out of the controlled environment of the ICU, or
experience considerable blood loss.
Because fever can have many infectious and noninfectious etiologies,
a new fever instead should trigger a careful clinical assessment. “It’s
important to make sure the measurement of temperature is an accurate
reflection of the patient’s physiology,” said lead author Naomi P.
O'Grady, MD, senior staff physician in the critical care medicine
department of the National Institutes of Health. Any unexplained
temperature elevation merits a clinical assessment that includes a
review of the patient’s history and a focused physical examination
before any lab tests or imaging procedures are ordered.
The new guidelines include a discussion of novel technologies to
measure temperature, with the most accurate being pulmonary artery
thermistor, urinary bladder catheter thermistor, esophageal probe, and
rectal probe. Technologies to avoid include temporal artery
thermometer, axillary thermometer and chemical dot.
A section on blood cultures reports that new data suggest that the
cumulative yield of pathogens is optimized when three to four blood
cultures are drawn within the first 24 hours of suspected bacteremia or
The guidelines include specific recommendations for evaluation of:
- pulmonary infections and ICU-acquired pneumonia, including an evaluation of new technologies
- gastrointestinal tracts of patients who are at risk for Clostridium difficile, including a discussion of common antigen testing and follow up
- urinary tracts for infections related to urinary catheters including bacteriuria and candiduria
- fever within 72 hours of surgery
- surgical site infections
- central nervous system infections
The guidelines also make recommendations about other considerations
such as the use of biomarkers to determine the cause of fever and how
to recognize noninfectious causes of fever, such as new medications.
Finally, the guidelines conclude with an expanded discussion of
empiric therapy for unstable or high-risk patients while the diagnostic
evaluation is ongoing.
The “Guidelines for Evaluation of New Fever in Critically Ill Adult
Patients: 2008 Update from the American College of Critical Care
Medicine and the Infectious Diseases Society of America,” were
published in Critical Care Medicine. (O’Grady et al., Crit Care Med. 2008;36:1330-49.)
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