Distinguishing Central From Infectious Fever in Neuro ICU
Hocker SE, Tian L, Li G, Steckelberg JM, Mandrekar JN, Rabinstein AA
JAMA Neurol. 2013;70:1499-1504
Critically ill patients with neurologic disease often have fever. As increasing numbers of super-resistant micro-organisms emerge, identification of central fever may facilitate antibiotic stewardship. The investigators therefore aimed to develop a model to differentiate central from infectious fever in critically ill neurologic patients with fever of undetermined cause.
Using data collected from January 1, 2006, through December 31, 2010, at a 20-bed neurologic intensive care unit (ICU) of a large teaching hospital, the investigators identified 526 consecutive patients who met inclusion criteria (age ≥ 18 years; admitted for at least 48 hours; and core body temperatures > 38.3°C on at least 1 measurement for 2 consecutive days). Patients in whom alternative causes of noninfectious fever were identified were excluded.
Infectious fever was defined by a pathogenic species growing in culture or a documented clinical diagnosis of infection treated with antibiotics, and central fever was considered the absence of the above. Persistent fever was characterized by continuous duration exceeding 6 hours on at least 2 consecutive days.
Compared with the 246 patients (46.8%).who had central fever, those with infectious fever were older (mean age, 57.4 vs 53.5 years; P = .01) and had a longer duration of stay in the neurologic ICU (mean, 12.1 vs 8.8 days; P < .001). Compared with infectious fever, central fever was more likely to occur within 72 hours of neurologic ICU admission (76.4% vs 60.7%; P < .001) and to be persistent (26.4% vs 18.6%; P = .04).
Multivariable analysis showed that independent predictors of central fever were blood transfusion (odds ratio [OR], 3.06; 95% confidence interval [CI], 1.63-5.76); chest x-ray clear of infiltrate (OR, 3.02; 95% CI,1.81-5.05); diagnosis of subarachnoid hemorrhage, intraventricular hemorrhage, or tumor (OR, 6.33; 95% CI, 3.72-10.77); and onset of fever within 72 hours of hospital admission (OR, 2.20; 95% CI,1.23-3.94). In contrast, patients with central and infectious fever did not differ in systemic inflammatory response syndrome or leukocytosis.
The probability of central fever was 0.90 in patients who had negative cultures; no infiltrate on chest x-ray; a diagnosis of subarachnoid hemorrhage, intraventricular hemorrhage, or tumor; and onset of fever within 72 hours of admission.
The limitations of this study include the fact that it was a retrospective analysis of a derivation cohort, has limited generalizability, was unable to account for potential overlap of fever origin, and lacked data on antibiotic administration before neurologic ICU admission or on procalcitonin levels. If this model to differentiate central fever from infectious fever in critically ill neurologic patients is validated in future studies, it may allow clinicians to select patients in whom antibiotics may be safely discontinued despite ongoing fever.
Abstract
Indicators of Central Fever in the Neurologic Intensive Care Unit
Hocker SE, Tian L, Li G, Steckelberg JM, Mandrekar JN, Rabinstein AA
JAMA Neurol. 2013;70:1499-1504
Study Summary
Critically ill patients with neurologic disease often have fever. As increasing numbers of super-resistant micro-organisms emerge, identification of central fever may facilitate antibiotic stewardship. The investigators therefore aimed to develop a model to differentiate central from infectious fever in critically ill neurologic patients with fever of undetermined cause.
Using data collected from January 1, 2006, through December 31, 2010, at a 20-bed neurologic intensive care unit (ICU) of a large teaching hospital, the investigators identified 526 consecutive patients who met inclusion criteria (age ≥ 18 years; admitted for at least 48 hours; and core body temperatures > 38.3°C on at least 1 measurement for 2 consecutive days). Patients in whom alternative causes of noninfectious fever were identified were excluded.
Infectious fever was defined by a pathogenic species growing in culture or a documented clinical diagnosis of infection treated with antibiotics, and central fever was considered the absence of the above. Persistent fever was characterized by continuous duration exceeding 6 hours on at least 2 consecutive days.
Compared with the 246 patients (46.8%).who had central fever, those with infectious fever were older (mean age, 57.4 vs 53.5 years; P = .01) and had a longer duration of stay in the neurologic ICU (mean, 12.1 vs 8.8 days; P < .001). Compared with infectious fever, central fever was more likely to occur within 72 hours of neurologic ICU admission (76.4% vs 60.7%; P < .001) and to be persistent (26.4% vs 18.6%; P = .04).
Multivariable analysis showed that independent predictors of central fever were blood transfusion (odds ratio [OR], 3.06; 95% confidence interval [CI], 1.63-5.76); chest x-ray clear of infiltrate (OR, 3.02; 95% CI,1.81-5.05); diagnosis of subarachnoid hemorrhage, intraventricular hemorrhage, or tumor (OR, 6.33; 95% CI, 3.72-10.77); and onset of fever within 72 hours of hospital admission (OR, 2.20; 95% CI,1.23-3.94). In contrast, patients with central and infectious fever did not differ in systemic inflammatory response syndrome or leukocytosis.
The probability of central fever was 0.90 in patients who had negative cultures; no infiltrate on chest x-ray; a diagnosis of subarachnoid hemorrhage, intraventricular hemorrhage, or tumor; and onset of fever within 72 hours of admission.
Viewpoint
The limitations of this study include the fact that it was a retrospective analysis of a derivation cohort, has limited generalizability, was unable to account for potential overlap of fever origin, and lacked data on antibiotic administration before neurologic ICU admission or on procalcitonin levels. If this model to differentiate central fever from infectious fever in critically ill neurologic patients is validated in future studies, it may allow clinicians to select patients in whom antibiotics may be safely discontinued despite ongoing fever.
Abstract
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