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Special Article

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

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 Societyof 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 wasobtained. 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

relationshipbetween 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 assessmentrather 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. (Crit Care Med 2008;36:1330–1349) KEY WORDS: fever; intensive care unit; critical illness; blood cultures; catheter infection; pneumonia; colitis; sinusitis; surgical site infection; nosocomial infection; temperature measurement; urinary tract infection

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n some intensive care units (ICUs), the measurement of a newly elevated temperature triggers an automatic order set that includes many tests that are time consuming,costly, and disruptive to the pa-

tient and staff. Moreover, the patient may experience discomfort, be exposed to unneeded radiation, require transport outside the controlled environment of the ICU, or experience considerable blood loss due to this testing, which is often

From the National Institutes of Health, Bethesda, MD (NPO, HM); Weill Cornell Medical College, New York, NY (PSB); JohnsHopkins University School of Medicine, Baltimore, MD (JGB, KC); Northwestern 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 individualsfor 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...