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SCCM and IDSA Guidelines for Evaluating New Fever in Adult Patients in the ICU

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Naomi P. O'Grady, MD, FIDSA, FCCM Stanley Deresinski, MD, FIDSA
PUBLISHED: 10/19/2023

Citation: O'Grady NP, Alexander E, Alhazzani W, et al. Society of Critical Care Medicine and the Infectious Diseases Society of America guidelines for evaluating new fever in adult patients in the ICU. Crit Care Med. 2023 Nov;51(11):1570-1586.

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RATIONALE: Fever is frequently an early indicator of infection and often requires rigorous diagnostic evaluation.

OBJECTIVES: This is an update of the 2008 Infectious Diseases Society of America (IDSA) and Society of Critical Care Medicine (SCCM) guidelines for the evaluation of new-onset fever in adult ICU patients without severe immunocompromise, now using Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology.

PANEL DESIGN: SCCM and IDSA convened a panel to update the 2008 guidelines for the evaluation of new fever in critically ill adult patients, which included expert clinicians as well as methodologists from the Guidelines in Intensive Care, Development, and Evaluation Group. The guidelines panel consisted of 12 experts in critical care, infectious diseases, clinical microbiology, organ transplantation, public health, clinical research, and health policy and administration. All panel members followed all conflict-of-interest procedures as documented in the American College of Critical Care Medicine/SCCM Standard Operating Procedures Manual and the IDSA. No industry input or funding was used to develop these guidelines.

METHODS: The panel conducted a systematic review for each population, intervention, comparison, and outcomes question to identify the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the GRADE approach. The panel used the evidence-to-decision framework to formulate recommendations as strong or weak or as best-practice statements.

RESULTS: The panel issued 12 recommendations and nine best practice statements. The panel recommended using central temperature monitoring methods, including thermistors for pulmonary artery catheters, bladder catheters, or esophageal balloon thermistors when these devices are in place or accurate temperature measurements are critical for diagnosis and management. For patients without these devices in place, oral or rectal temperatures over other temperature measurement methods that are less reliable such as axillary or tympanic membrane temperatures, noninvasive temporal artery thermometers, or chemical dot thermometers were recommended. Imaging studies including ultrasonography were recommended in addition to microbiologic evaluation using rapid diagnostic testing strategies. Biomarkers were recommended to assist in guiding the discontinuation of antimicrobial therapy. All recommendations issued were weak based on the quality of data.

CONCLUSIONS: The guidelines panel formulated several recommendations for the evaluation of new fever in critically ill adult patients, acknowledging that most recommendations were based on weak evidence, which highlights the need for the rapid advancement of research in all aspects of fever, including better noninvasive methods to measure core body temperature, the use of diagnostic imaging, advances in microbiology including molecular testing, and the use of biomarkers.

KEY WORDS: diagnosis; evaluation; fever; guidelines; infection; temperature measurement

Guideline Type: Clinical

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Central temperature monitoring methods, including thermistors for pulmonary artery catheters, bladder catheters, or esophageal balloon thermistors, are preferred when these devices are in place or accurate temperature measurements are critical to diagnosis and management. For patients without these devices in place, we suggest using oral or rectal temperatures over other temperature measurement methods that are less reliable (such as axillary or tympanic membrane temperatures, noninvasive temporal artery thermometers, or chemical dot thermometers).
Quality of evidence: Very low

For critically ill patients with fever, we suggest avoiding the routine use of antipyretic medications for the specific purpose of reducing the temperature.
Quality of evidence: Moderate

For critically ill patients with fever who value comfort by reducing temperature, we suggest using antipyretic medications over nonpharmacologic methods to reduce body temperature.
Quality of evidence: Low

For patients who develop a fever during their ICU stay, we recommend performing a chest radiograph.

For patients who have recently undergone thoracic, abdominal, or pelvic surgery, we recommend performing CT (in collaboration with the surgical service) as part of a fever workup if an etiology is not readily identified by the initial workup.

For critically ill patients with fever in whom other diagnostic tests have failed to establish an etiology, we suggest performing an 18F-fluorodeoxyglucose (18F-FDG) PET or CT if the risk of transport is deemed acceptable.
Quality of evidence: Very low

The panel found insufficient evidence to issue a recommendation regarding the use of WBC scans for patients with fever without an established etiology.

For critically ill patients with fever and no abdominal signs or symptoms or liver function abnormalities and no recent abdominal surgery, we recommend against the routine use of a formal abdominal ultrasound or POCUS as an initial investigation.

In patients with fever and recent abdominal surgery or in any patient with either abdominal symptoms or suspicion of an abdominal source (e.g., abnormal physical examination/POCUS, increased transaminases, or alkaline phosphatase, and/or bilirubin), we recommend performing a formal bedside diagnostic ultrasound of the abdomen.

For critically ill patients with fever and an abnormal chest radiograph, we suggest performing a thoracic bedside ultrasound when sufficient expertise is available to reliably identify pleural effusions and parenchymal or interstitial lung pathology.
Quality of evidence: Low

The panel found insufficient evidence to issue a recommendation regarding the use of thoracic bedside ultrasound for patients with fever without chest radiograph abnormalities.

For ICU patients with fever without an obvious source and who have a central venous catheter, we recommend simultaneous collection of central venous catheter and peripherally drawn blood cultures to allow calculation of differential time to positivity.

In patients with fever in the ICU in whom central venous catheter cultures are indicated, we recommend sampling at least two lumens.

For critically ill patients with a new fever of unclear origin, we suggest that, if rapid molecular tests on blood are performed, they should be used only with concomitant blood cultures.
Quality of evidence: Very low

When performing blood cultures in adult ICU patients, we recommend sequentially collecting at least two sets of blood cultures (ideally 60 mL of blood total), from different anatomic sites, without a time interval between them.

For febrile ICU patients with pyuria and in whom UTI is suspected, we recommend replacing the urinary catheter and obtaining urine cultures from the newly placed catheter.

For critically ill patients with new fever and suspected pneumonia, or new upper respiratory infection symptoms (e.g., cough), we suggest testing for viral pathogens using viral NAAT panels.
Quality of evidence: Very low

The panel found insufficient evidence to issue a recommendation on performing routine blood testing for viral pathogens (e.g., herpesviruses, adenovirus) in immunocompetent patients in the ICU.

For critically ill patients with a new fever, we recommend testing for SARS-CoV-2 by PCR based on levels of community transmission.

If the probability of bacterial infection is deemed low to intermediate in a critically ill patient with a new fever and no clear focus of infection, we suggest measuring PCT in addition to bedside clinical evaluation versus bedside clinical evaluation alone.
Quality of evidence: Very low

If the probability of bacterial infection is deemed high in a critically ill patient with a new fever and no clear focus of infection, we suggest not measuring PCT to rule out bacterial infection.
Quality of evidence: Very low

If the probability of bacterial infection is deemed low to intermediate in a critically ill patient with a new fever and no clear focus of infection, we suggest measuring CRP in addition to bedside clinical evaluation versus bedside clinical evaluation alone.
Quality of evidence: Very low

If the probability of bacterial infection is deemed high in a critically ill patient with a new fever and no clear focus of infection, we suggest not measuring CRP to rule out bacterial infection.
Quality of evidence: Very low

If the probability of bacterial infection is deemed low to intermediate in a critically ill patient with a new fever and no clear focus of infection, we suggest measuring either serum PCT or CRP to rule out bacterial infection.
Quality of evidence: Very low

CRP, C-reactive protein; CT, computed tomography; NAAT, nucleic acid amplification test; PCR, polymerase chain reaction; PCT, procalcitonin; PET, positron emission tomography; POCUS, point-of-care ultrasound; UTI, urinary tract infection; WBC, white blood cell.

Naomi P. O'Grady, MD, FIDSA, FCCM
Author
Naomi P. O'Grady, MD, FIDSA, FCCM
Naomi P. O’Grady, MD, FIDSA, FCCM, is chief of the Internal Medicine Service and an attending physician in the Critical Care Medicine Department of the National Institutes of Health Clinical Center, Bethesda, Maryland, USA. She served as chair of the panel that developed the guidelines for evaluating new fever in adult patients in the ICU.
Stanley Deresinski, MD, FIDSA
Author
Stanley Deresinski, MD, FIDSA
Stanley Deresinski, MD, FIDSA, is a clinical professor of medicine in the Division of Infectious Diseases at the University of Nebraska Medical Center in Omaha, Nebraska, USA. He served as cochair of the panel that developed the guidelines for evaluating new fever in adult patients in the ICU.

A complete list of the guidelines authors and contributors is available within the published manuscript.

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