New Fever in ICU

• Temperature >101 F warrants work-up, lower in immunocompromised
  
• Fever may not reflect an infectious cause all the time
  
• Infections may not cause fever or may even cause hypothermia
  
• Infections may manifest as hemodynamic instability, tachycadria, confusion, rigors, oliguria, leukoctosis
  
• Work-up:
  
  • Blood cultures
    
  • Consider specific cultures for fungal and mycobacteria
    
  • Obtain 3-4 cultures/24h
    
• Line Sepsis:
  
  • Recovery of certain microorganisms in multiple blood cultures, such as staphylococci, Corynebacterium jeikeium, Bacillus species, atypical mycobacteria, Candida, or Malassezia species, strongly suggest infection of an intravascular device.
    
• Pulmonary infections:
  
  • Difficult to diagnose
    
  • Chest x-ray: unilateral air bronchograms have been shown to have the best predictive value for pneumonia.
    
  • CT imaging is also valuable in immunocompromised patients
    
  • Bronchoscopy: especially useful for :Pneumocystis jiroveci, Aspergillus and other filamentous fungi, Nocardia, Legionella, cytomegalovirus (CMV), and Mycobacterium species
    
  • Virtually always pathogebs: Legionella, Chlamydia, M. tuberculosis, Rhodococcus equi, influenza virus, respiratory syncytial virus, parainfluenza virus, Strongyloides, Toxoplasma gondii, P. jiroveci, Histoplasma capsulatum, Coccidioides immitis, Blastomyces dermatitidis, and Cryptococcus neoformans.
    
  • Isolation of enterococci, viridans streptococci, coagulase-negative staphylococci, and Candida species should rarely if ever be considered the cause of respiratory dysfunction
    
• Gastrointestinal infections:
  
  • C difficile infections
    
  • Sending stools for bacterial cultures or ova and parasite examination should generally be avoided as part of a fever evaluation unless the patient was admitted to the hospital with diarrhea, is infected with HIV, or is a part of an outbreak evaluation.
    
  • Consider CMV in solid organ transplant
    
  • Consider Acute neutropenic enterocolitis or typhlitis caused by enteric Gram-negative bacilli (i.e., Pseudomonas species) or anaerobes (i.e., Clostridium septicum) should be sought in cancer or stem cell transplant
    
• Urinary Tract infection:
  
• Sinusitis
  
• Post-operative Fever
  
• Surgical Site Infections
  
• Central nervous system infections
  
• Non-infectious causes of fever:
  
  • Acalculous cholecystitis
    
  • Acute myocardial infarction
    
  • Adrenal insufficiency
    
  • Blood product transfusion
    
  • Cytokine-related fever
    
  • Dressler syndrome (pericardial injury syndrome)
    
  • Drug fever
    
  • Fat emboli
    
  • Fibroproliferative phase of acute respiratory
    
  • Gout
    
  • Heterotopic ossification
    
  • Immune reconstitution inflammatory syndrome
    
  • Intracranial bleed
    
  • Jarisch-Herxheimer reaction
    
  • Pancreatitis
    
  • Pulmonary infarction
    
  • Pneumonitis without infection
    
  • Stroke
    
  • Thyroid storm
    
  • Transplant rejection
    
  • Tumor lysis syndrome
    
  • Venous thrombosis

Original article from IDSA guidelines