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Guidelines for evaluation of new fever in critically ill adult patients: 2008 update from the American College of Critical Care Medicine and the Infectious Diseases Society of America

O’Grady, Naomi P. MD; Barie, Philip S. MD, MBA, FCCM; Bartlett, John G. MD; Bleck, Thomas MD, FCCM; Carroll, Karen RN; Kalil, Andre C. MD; Linden, Peter MD; Maki, Dennis G. MD; Nierman, David MD, FCCM; Pasculle, William MD; Masur, Henry MD, FCCM

doi: 10.1097/CCM.0b013e318169eda9
Special Article

Objective: To update the practice parameters for the evaluation of adult patients who develop a new fever in the intensive care unit, for the purpose of guiding clinical practice.

Participants: A task force of 11 experts in the disciplines related to critical care medicine and infectious diseases was convened from the membership of the Society of Critical Care Medicine and the Infectious Diseases Society of America. Specialties represented included critical care medicine, surgery, internal medicine, infectious diseases, neurology, and laboratory medicine/microbiology.

Evidence: The task force members provided personal experience and determined the published literature (MEDLINE articles, textbooks, etc.) from which consensus was obtained. Published literature was reviewed and classified into one of four categories, according to study design and scientific value.

Consensus Process: The task force met twice in person, several times by teleconference, and held multiple e-mail discussions during a 2-yr period to identify the pertinent literature and arrive at consensus recommendations. Consideration was given to the relationship between the weight of scientific evidence and the strength of the recommendation. Draft documents were composed and debated by the task force until consensus was reached by nominal group process.

Conclusions: The panel concluded that, because fever can have many infectious and noninfectious etiologies, a new fever in a patient in the intensive care unit should trigger a careful clinical assessment rather than automatic orders for laboratory and radiologic tests. A cost-conscious approach to obtaining cultures and imaging studies should be undertaken if indicated after a clinical evaluation. The goal of such an approach is to determine, in a directed manner, whether infection is present so that additional testing can be avoided and therapeutic decisions can be made.

From the National Institutes of Health, Bethesda, MD (NPO, HM); Weill Cornell Medical College, New York, NY (PSB); Johns Hopkins University School of Medicine, Baltimore, MD (JGB, KC); North-western University, Chicago, IL (TB); University of Nebraska, Omaha, NE (ACK); University of Pittsburgh Medical Center, Pittsburgh, PA (PL, WP); University of Wisconsin Medical School, Madison, WI (DGM); and The Mount Sinai Hospital, New York, NY (DN).

The American College of Critical Care Medicine (ACCM), which honors individuals for their achievements and contributions to multidisciplinary critical care medicine, is the consultative body of the Society of Critical Care Medicine (SCCM), which possesses recognized expertise in the practice of critical care. The College has developed administrative guidelines and clinical practice parameters for the critical care practitioner. New guidelines and practice parameters are continually developed, and current ones are systematically reviewed and revised.

This guideline was developed in collaboration with the Infectious Diseases Society of America.

For information regarding this article, E-mail: nogrady@mail.cc.nih.gov

Dr. Bartlett holds consultancies with HIV-Bristol-Myers, Abbott, Merck, Johnson & Johnson, and Tibotec; and a patent with Gilead.

The remaining authors have not disclosed any potential conflicts of interest.

© 2008 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins