Society of Critical Care Medicine and the Infectious Diseases Society of America Guidelines for Evaluating New Fever in Adult Patients in the ICU

Abstract

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 and Society (IDSA) and Society of Critical Care Medicine (SCCM) guideline for the evaluation of new-onset fever in adult ICU patients without severe immunocompromise, now using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. PANEL DESIGN: The SCCM and IDSA convened a taskforce to update the 2008 version of the guideline 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 committee consisted of 12 experts in critical care, infectious diseases, clinical microbiology, organ transplantation, public health, clinical research, and health policy and administration. All task force 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. There was no industry input or funding to produce this guideline. METHODS: We 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. We 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 9 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 microbiological 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 was able to formulate several recommendations for the evaluation of new fever in a critically ill adult patient, acknowledging that most recommendations were based on weak evidence. This highlights the need for the rapid advancement of research in all aspects of this issue—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.

Should Blood Cultures Be Drawn Through an Indwelling Catheter?

“…The motivation behind this change in practice reflects the fact that central line-associated bloodstream infections are associated with potential loss of hospital reimbursement from the Centers for Medicare & Medicaid Services and third-party payers, as well as potential damage to institutional reputation. However, this practice is based on older studies [ 1 , 2 ] before the increasing use of port protectors [ 3 , 4 ] and conflicts with Infectious Diseases Society of America guidelines [ 5 , 6 ]. Additionally, how can a clinician definitively diagnose a catheter-related bloodstream infection (CRBSI) if only percutaneously drawn cultures are obtained unless the patient has purulent drainage from the insertion site (uncommon in patients with infected CVCs; more common with infected short-term peripheral venous catheters), or the catheter is removed and the tip is cultured revealing the same microbe as in the blood?…”

Executive Summary: Guidelines for Evaluating New Fever in Adult Patients in the ICU

“…The consensus recommendations are summarized and listed in Table 2 of the full guidelines document (1). Selected recommendations that are new or require special attention are listed here in Table 1 .…”

“…Readers will find rationales for 24 recommendations or statements derived from actionable Population, Intervention, Comparison, Outcome questions, or best practice statements in which GRADE methodology was not used. The supplemental digital figures and tables provide background on how the questions were developed, profiles of the evidence, the evidence-to-decision tables used to develop the recommendations, and the voting results (1). We also acknowledge the evidence gaps that exist which allow for only weak recommendations and preclude addressing all clinical priority questions.…”

Changing the culture: impact of a diagnostic stewardship intervention for urine culture testing and CAUTI prevention in an urban safety-net community hospital

“…Due to these limitations, the Society of Critical Care Medicine (SCCM) and the Infectious Diseases Society of America (IDSA) advise against the routine use of urine cultures for the workup of fever in critically ill patients with catheters unless symptoms are present, highlighting the importance of a thorough history and physical examination to guide possible diagnostic studies for infectious and noninfectious sources. 3 , 4 These guidelines recommend urine cultures for the workup of fever in transplant recipients, neutropenia, genitourinary surgery, and obstruction. 3 , 4 However, urine cultures are frequently ordered without indication.…”

“… 3 , 4 These guidelines recommend urine cultures for the workup of fever in transplant recipients, neutropenia, genitourinary surgery, and obstruction. 3 , 4 However, urine cultures are frequently ordered without indication. 1 , 2 Indiscriminate testing can lead to misinterpretation of results, erroneous diagnosis of catheter-associated urinary tract infections (CAUTIs), excess antimicrobial use, resistance, and C difficile infections.…”