Assessment of New Fever in Adult ICU Patients: Guidelines from SCCM and IDSA

Fever typically signals an infection early on and necessitates a thorough diagnostic assessment.

The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology is being used in this 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.

A panel was constituted by SCCM and IDSA in order to revise the 2008 recommendations for the assessment of new fever in critically sick adult patients. TThe panellve suggestions and nine best practice statements The panelre released by the group.

When these devices are in use or precise temperature readings are essential for diagnosis and treatment, central temperature monitoring techniques—such as thermistors for bladder catheters, esophageal balloon thermistors, or pulmonary artery catheter thermistors—are recommended. The panel recommend oral or rectal temperature taking over less accurate techniques (such tympanic or axillary membrane temperatures, noninvasive temporal artery thermometers, or chemical dot thermometers) for individuals who do not have these instruments.

The panel advised against routinely giving antipyretic drugs to severely sick individuals who have fevers only to loThe panelr their body temperature.

The panel rrecommended ntipyretic medicine over nonpharmacologic techniques of temperature reduction for critically sick individuals with fever who prioritise comfort via temperature reduction.

The panel advised doing a chest radiograph on patients who have fever throughout their stay in the intensive care unit.

If an aetiology is not easily established by the first workup, The panel advise doing CT (in coordination with the surgical department) as part of a fever workup for patients who have recently had thoracic, abdominal, or pelvic surgery.

When no other diagnostic test has been able to determine the cause of a fever in critically unThe panelll patients, The panel recommend doing an 18F-fluorodeoxyglucose (18F-FDG) PET or CT scan if the risk of transport is considered tolerable.

The panel concluded that there was not enough data to make a recommendation for WBC scans for individuals with fever who did not have a known cause.

The panel advised against routinely using a formal abdominal ultrasound or POCUS as a first assessment for critically sick patients with fever, no abdominal signs or symptoms, abnormal liver function, and no recent abdominal surgery.

The panel advised doing a formal bedside diagnostic ultrasound of the abdomen in patients with fever and recent abdominal surgery, as The panelll as in any patient with abdominal symptoms or suspicion of an abdominal source (e.g., abnormal physical examination/POCUS, increased transaminases, alkaline phosphatase, and/or bilirubin).

When enough experience is available to accurately diagnose pleural effusions and parenchymal or interstitial lung disease, The panel recommend a thoracic bedside ultrasonography for critically unThe panelll patients with fever and an abnormal chest radiograph.

Regarding the use of thoracic bedside ultrasonography for patients with fever who do not have abnormal chest radiographs, the panel determined that there was not enough data to make a recommendation.

In order to calculate the differential time to positive, The panel advise concurrent collection of peripherally obtained blood cultures and central venous catheter for ICU patients with fever who have no apparent cause.

The panel advise sampling at least two lumens from patients with fever in the intensive care unit (ICU) when central venous catheter cultures are necessary.

If quick molecular tests on blood are conducted for critically sick patients with a new fever of uncertain origin, The panel recommend that they be utilised only in conjunction with concurrent blood cultures.

It is recommended to collect blood cultures from adult ICU patients in a sequential manner, preferably using 60 mL of total blood from multiple anatomic locations, without a time lapse in betThe panelen.

Urine cultures should be obtained from the newly inserted urinary catheter in febrile ICU patients who have pyuria and are suspected of having a UTI.

The panel recommended employing viral NAAT panels to screen for viral pathogens in critically ill patients with new fever and probable pneumonia, as The panelll as new signs of upper respiratory infections (e.g., cough).

The panel concluded that there was not enough data to make a recommendation regarding regular blood testing for viral infections (such as adenovirus and herpesvirus) in immunocompetent ICU patients.

Based on levels of community transmission, The panel advise PCR testing for SARS-CoV-2 in critically ill patients with a new fever.

The panel recommends evaluating PCT in addition to bedside clinical examination against bedside clinical evaluation alone if the risk of bacterial infection is determined to be low to intermediate in a critically sick patient with a new fever and no obvious focus of infection.

The panel recommends not testing PCT to rule out bacterial infection if the chance of bacterial infection is considered high in a critically unThe panelll patient with a new fever and no obvious centre of infection.

The panel recommends evaluating CRP in addition to bedside clinical examination against bedside clinical evaluation alone if the risk of bacterial infection is determined to be low to intermediate in a critically sick patient with a recent fever and no obvious focus of infection.

The panel advise against testing CRP to rule out bacterial infection in critically ill patients with a new fever and unclear infection focus if the likelihood of bacterial infection is thought to be high.

The panel recommend evaluating either serum PCT or CRP to rule out bacterial infection if the chance of bacterial infection is considered low to intermediate in a critically unThe panelll patient with a new fever and no obvious focus of infection.

Reference –

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.