|
 

Simranjit Singh Galhotra, MD, MBA

George Washington University
Fellow, Pulmonary and Critical Care Medicine
January 1998
|
  
0 Äippocrates recognized fever as a beneficial
sign during infection
0 Thomas Sydenham (16þ
1689), English
physician: ³Fever is Nature¶s engine which
she brings into the field to remove her
enemy.´
0 Fever therapy used in many societies world

wide
þ
|
  
0hiebermeister, German physician
Fever is the regulation of body
temperature at a higher level
Fever dangerous if too high or
prolonged
Antipyretic drugs should be used only
for high fevers or of long duration

Î
|
  
0Antipyretic drugs widely available: aspirin,
other salicylates
0Many physicians advocated reducing fever
0Fever considered harmful by
product of
infection, not host
defense response
0Why? Perhaps because salicylates are
analgesic O
antipyretic
-

0Fever is energetically costly
0In mammals increasing temperature þ
Î C
increases energy consumption þ
0Since such a response is preserved across
invertebrates and vertebrates, fever must
have an adaptive function

A
—  
- 
0 Enhanced neutrophil migration
0 Increased production of antibacterial
substances by neutrophils
0 Increased production of interferon
0 Increased antiviral and antitumor activity of
interferon
0 Increased T
cell proliferation

*Kluger MJ. Inf Dis Clin of NA 1:1
þ, 1996 6

r|


0Äospital
acquired fevers occur

in one
third of all medical
inpatients
0Nosocomial fevers even more
common in the ICU

´
|
 

0 ICU patients have several underlying

medical/surgical conditions
0 ICU patients undergo many invasive
diagnostic and therapeutic procedures
0 Therefore, fever in ICU patients must be
thoroughly and promptly evaluated to
discriminate infectious from non
infectious
etiologies
8


0Fever is a non
specific sign seen in
inflammatory processes that may be
infectious
noninfectious, including neoplastic
0The ³1þ Rule´

9
£  !
0 Acute cholecystitis 0 Acute pancreatitis
0 Acute MI 0 Pulmonary embolism
0 Dressler¶s Syndrome or infarct
0 Thrombophlebitis 0 Viral hepatitis

0 GI bleed 0 Uncomplicated
wound infection

1
£  
0 Cholangitis 0 Non
viral liver
0 Suppurative phlebitis disease: drug fever,
0 Pericarditis
leptospirosis«
0 Complicated wound
0 Septicpulmonary
embolism infection
0 Bowel infarction
0 Pancreatic abscess

11
  |
 

0 SIRS 0 Urinary catheter

0 Intravenous
line associated bacteriuria
infections 0 Drug fever
0 Nosocomial 0 Post
operative fever
pneumonia 0 Neurosurgical causes
0 Nosocomial sinusitis
0 Intraabdominal
infections

1þ
 "  #

0Definition of SIRS
T > Î8 C or < Î6 C
ÄR > 9
RR > þ or pCOþ < Îþ
WBC > 1þ or <

1Î
"
0Often noninfectious etiology found:
Pulmonary embolism
Myocardial infarction
Gastrointestinal bleed
Acute pancreatitis
Cardiopulmonary bypass

1

$  
0Prevalence: A in ICU patients in a
University of VA study of triple
lumen
and pulmonary artery catheters*
0Bloodstream infection is a serious
catheter
related complication: case
fatality rate ~1
þ

*Cobb DK. NEJM Îþ´:16þ
8, 199þ

1A

$  
0hook for local signs of infection:
present in < A
0Remove line if no other source
and T > 1þ

16
 # #"   %
0UVA study*
Inclusion criteria:
criteria All patients admitted to
the ICU who needed triple
lumen central
venous catheters or pulmonary artery
catheters inserted via SC or IJ for > Î days

*Cobb DK. NEJM Îþ´:16þ
8, 199þ

1´
 # #"   %
0Four groups
1 replaced q Î days with a new stick
þ replaced every Î days over guidewire
Î replaced only if clinically indicated
(fever, mechanical complications)
with new stick
replaced only if clinically indicated
over guidewire
18
 # #"   %
0 Total of 16 patients enrolled; AþÎ catheters.
0 No statistically significant difference in
catheter
related bloodstream infections
among groups
0 Statistically significant increase in
mechanical complications with new sticks
vs. guidewire exchange

19
 # #"   %
0No support for changing lines every Î
A
days; change only if unexplained fever or
catheter malfunction occurs
0Concurs with CDC¶s @



 

 
O O O

O

 

 . Am J Infect Control
1996;þ :þ6þ
þ9Î
þ
r 
0Almost all cases occur in mechanically
ventilated patients
0Signs are
fever
leukocytosis
purulent tracheal secretions
new or worsening infiltrates on CXR

þ1
r 
0 Äowever, none of these are predictive of
pneumonia; nosocomial pneumonia remains a
clinical diagnosis
0 Can be confused with fibroproliferative phase of
ARDS, usually accompanied by low
grade fever
0 Semi
quantitative BAh and protected
brush
specimen may be helpful, but not widely available

þþ
r
0 Bacteriology differs markedly from
community
acquired disease
0 Gram
negative bacilli cause most cases in
intubated patients
0 Polymicrobial infection in upto A of cases,
reflecting ICU flora
0 Paranasal sinusitis accounts for about A of
nosocomial ICU infections
þÎ
r
0Fever and leukocytosis often
present
0Purulent nasal discharge often
O 

0Common in trauma and
neurosurgical units

þ
r
0 Risk factors
nasotracheal tubes
nasogastric tubes
nasal packing
facial fractures
steroid therapy
0 Diagnosis made easier with sinus CT, which is
more sensitive than plain films
0 Avoid prolonged nasotracheal intubation
þA
$&# 
0Suspect intra
abdominal abscess in
patients with prolonged post
operative
fever after abdominal surgery
0Acalculous cholecystitis and subsequent
biliary sepsis may complicate post

operative period

þ6
$&# 
0 Suspect antibiotic
associated colitis due to
a







 in patients on broad

spectrum antibiotics
0 Fever and leukocytosis may be present prior to
diarrhea or abdominal symptoms
0 Splenic or hepatic abscesses may complicate
other intra
abdominal infections (cholecystitis,
appendicitis) causing prolonged fevers
þ´
   $ # 
0Foley catheters
Result in acquisition of bacteriuria
Nearly always represents colonization, not
infection
Pyuria often accompanies CAB, mimicking
a UTI

þ8
   $ # 
0 Foley + high fever + bacteriuria
does not necessarily mean urosepsis
unless their is partial or total obstruction or
pre
existing renal disease
0 Asymptomatic CAB
in normal hosts need not be treated
in compromised hosts and chronically
immunosuppressed must be treated promptly
þ9

|

0Some Î
´ of fevers on an inpatient
medical service are drug reactions
0Äistory of atopy is a risk factor
0Patient may have been on the ³sensitizing
medication´ for days to years

Î

|

0On physical patient looks ³inappropriately
well´ for degree of fever
fever usually 1þ to 1
relative bradycardia
A
1 have rash

Î1

|

0hab tests show
leukocytosis with left shift
eosinophils on peripheral smear (common)
eosinophilia (low
grade)
elevated ESR
mildly elevated AP, AST, AhT

Îþ
   
|

0Antibiotics 0Antihypertensives
0Sleep medications 0Antidepressants
0Antiepileptics 0Antiarrhythmics
0Stool Softeners 0NSAIDs
0Diuretics

ÎÎ
"   
|

0 Digoxin 0 Erythromycins
0 Steroids 0 Chloramphenicol
0 Diphenhydramine 0 Vancomycin
0 Aspirin 0 Imipenim
0 Vitamins 0 Quinolones
0 Aminoglycosides
0 Tetracyclines

Î
 
|

0Fever common post
operatively
0Most episodes noninfectious
0Probably due to intraoperative tissue
trauma with subsequent release of
endogenous pyrogens into the
bloodstream

*Garibaldi RA. Infect Control 6:þ´Î, 198A

ÎA
 
|

0Garibaldi* found that ´þ of fevers
within the 8 after surgery were non

infectious
0Wound, urinary tract, and respiratory
infections occur later than 8

*Garibaldi RA. Infect Control 6:þ´Î, 198A

Î6
 
|

0 Empiric antibiotics should be withheld in
patients with fever within 8 of surgery if they
lack a specific diagnosis after thorough
evaluation
0 Continuing perioperative prophylactic
antibiotics does not prevent infection, only
selects for resistant organisms

δ
|
r  
0Most important causes are
Wound infection
Meningitis, an infrequent post
op
complication, especially after open

head trauma

Î8
|
r  
0Commonest clinical entity is posterior
fossa syndrome
stiff neck, low CSF glucose, elevated
protein, mostly neutrophils
Can occur after any intracranial procedure
Symptoms due to blood in CSF
Culture negative, and symptoms subside as
RBCs decrease over time in CSF
Î9
  |
'
 )
0 Central fevers
intracranial hemorrhage, head trauma,
infection, malignancy
especially if the base of the brain or
hypothalamus affected
0 Infusion
related sepsis (contaminated infusate)
0 Rarely, bacterial infection
0 Drug fever (usually 1þ to 16 )


  |
'
!(
0 Malignant hyperthermia
Rare genetic disorder, probably autosomal
dominant
Incidence 1:1A, in kids; less in adults
Äypercatabolic reaction to anesthetic drugs
Sustained muscle contraction
> excess heat
Tachycardia occurs in >9 of pts within Î
minutes
Treated with dantrolene; mortality ~´
1
  |
'
!(
0Malignant neuroleptic syndromes
Confusion, hyperthermia, muscle stiffness,
autonomic instability
Drugs implicated: phenothiazines,
thioxanthines, butyrphenones


antipsychotics, tranquilizers, and antiemetics
Dantrolene or bromocriptine, a dopamine
agonist, effective in uncontrolled studies

þ
 
0 Fever in the ICU can have many infectious and
noninfectious etiologies
0 Crucial to identify the precise cause as some of the
conditions in each groups are life
threatening, while
others require no treatment
0 ³Routine fever work
up´ not cost
effective
0 If initial evaluation shows no infection, antibiotics
should be withheld
0 Empiric antibiotics may be started in the unstable
patient, but stopped if infection is not evident later
Î