Evaluating New Fever in Adult Patients in the ICU

Publication Date: October 12, 2023
Last Updated: October 13, 2023

Consensus Recommendations

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). (Conditional, Very Low)
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For critically ill patients with fever, we suggest avoiding routine use of antipyretic medications for the specific purpose of reducing the temperature. (Conditional, Moderate)
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For critically ill patients with fever who value comfort by reducing temperature, we suggest using antipyretics over nonpharmacologic methods to reduce body temperature. (Conditional, Low)
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For patients who develop fever during ICU stay, we recommend performing a chest radiograph. (BPS, )
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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 initial workup. (BPS, )
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For critically ill patients with fever in whom other diagnostic tests have failed to establish an etiology, we suggest either performing an 18F-fluorodeoxyglucose positron emission tomography/CT if the risk of transport is deemed acceptable. (Conditional, Very Low)
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The panel found insufficient evidence to issue a recommendation regarding the use of WBC scan for patients with fever without an established etiology. (, )
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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 regular abdominal ultrasound or point-of-care ultrasound (POCUS) as an initial investigation. (BPS, )
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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. (BPS, )
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For critically ill patients with fever and an abnormal chest radiograph, we suggest performing a thoracic bedside ultrasound when sufficient expertise is available to more reliably identify pleural effusions and parenchymal or interstitial lung pathology. (Conditional, Low)
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Insufficient evidence was found to issue a recommendation regarding the use of thoracic bedside ultrasound for patients with fever without chest radiograph abnormalities. (, )
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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. (BPS, )
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In patients with fever in the ICU in whom central venous catheter cultures are indicated, we recommend sampling at least two lumens. (BPS, )
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For critically ill patients with a new fever of unclear origin, we suggest that if rapid molecular tests on blood are performed, they should only be used with concomitant blood cultures. (Conditional, Very Low)
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When performing blood cultures in adult ICU patients, we recommend collecting at least two sets of blood cultures (ideally 60 mL of blood total) one after the other, from different anatomical sites, without a time interval between them. (BPS, )
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For febrile ICU patients with pyuria and in whom urinary tract infection is suspected, we recommend replacing the urinary catheter and obtaining urine cultures from the newly placed catheter. (BPS, )
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For critically ill patients with a new fever and suspected pneumonia, or new upper respiratory infection symptoms (e.g., cough), we suggest testing for viral pathogens using viral nucleic acid amplification test panels. (Conditional, Very Low)
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There was insufficient evidence to allow a recommendation on performing routine blood testing for viral pathogens in immunocompetent patients in the ICU (e.g., herpesviruses, adenovirus). (, )
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For critically ill patients with a new fever, we recommend testing for severe acute respiratory syndrome coronavirus 2 by PCR based on levels of community transmission. (BPS, )
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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 procalcitonin (PCT) in addition to bedside clinical evaluation vs bedside clinical evaluation alone. (Conditional, Very Low)
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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. (Conditional, Very Low)
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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 C-reactive protein (CRP) in addition to bedside clinical evaluation vs bedside clinical evaluation alone. (Conditional, Very Low)
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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. (Conditional, Very Low)
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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 serum PCT or CRP to rule out bacterial infection. (Conditional, Very Low)
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Recommendation Grading

Abbreviations

  • CRP: C-reactive Protein
  • ICU: Intensive Care Unit
  • PCT: Procalcitonin
  • POCUS:

    point-of-care Ultrasound

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.

Overview

Title

Evaluating New Fever in Adult Patients in the ICU

Authoring Organizations

Publication Month/Year

October 12, 2023

Last Updated Month/Year

November 6, 2023

Document Type

Guideline

Country of Publication

US

Document Objectives

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.

Target Patient Population

Critically ill adult patients in the hospital or ICU presenting with new fever

Target Provider Population

Critical care, infectious diseases, clinical microbiology, organ transplantation, public health, clinical research, and health policy and administration

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Emergency care, Hospital

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Diagnosis, Assessment and screening

Diseases/Conditions (MeSH)

D003422 - Critical Care, D005334 - Fever, D016638 - Critical Illness, D007362 - Intensive Care Units

Keywords

intensive care, fever, ICU, intensive care unit, critically ill

Source Citation

O’Grady, Naomi P. MD, FCCM, FIDSA1; Alexander, Earnest PharmD, FCCM2; Alhazzani, Waleed MBBS, MSc, FRCPC3; Alshamsi, Fayez MBBS4; Cuellar-Rodriguez, Jennifer MD5; Jefferson, Brian K. DNP, ACNP-BC, FCCM6; Kalil, Andre C. MD, MPH, FCCM, FIDSA7; Pastores, Stephen M. MD, MACP, FCCP, FCCM8; Patel, Robin MD, FIDSA, FRCPC9,10; van Duin, David MD, PhD, FIDSA11; Weber, David J. MD, FIDSA, FSHEA, FRSM, FAST11; Deresinski, Stanley MD, FIDSA12. Society of Critical Care Medicine and the Infectious Diseases Society of America Guidelines for Evaluating New Fever in Adult Patients in the ICU. Critical Care Medicine 51(11):p 1570-1586, November 2023. | DOI: 10.1097/CCM.0000000000006022

Supplemental Methodology Resources

Data Supplement