William Pasculle

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

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.

Practice Parameters for Evaluating New Fever in Critically Ill Adult Patients. Task Force of the American College of Critical Care Medicine of the Society of Critical Care Medicine in Collaboration with the Infectious Disease Society of America.

Abstract Objective: To develop practice parameters for the evaluation of adult patients who develop a new fever in the intensive care unit (ICU) for the purpose of guiding clinical practice. Participants: A task force of 13 experts in disciplines related to critical care medicine, infectious diseases, and surgery was convened from the membership of the Society of Critical Care Medicine, and the Infectious Disease Society of America. Evidence: The task force members provided the personal experience and determined the published literature (MEDLINE articles, textbooks, etc.) from which consensus would be sought. Published literature was reviewed and classified into one of four categories, according to study design and scientific value. Consensus Process: The task force met several times in person and twice monthly by teleconference over a 1‐yr period of time to identify the pertinent literature and arrive at consensus recommendations. Consideration was given to the relationship between the weight of scientific evidence and the experts’ opinions. 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 ICU 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 it is indicated after a clinical evaluation. The goal of such an approach is to determine, in a directed manner, whether or not infection is present, so additional testing can be avoided and therapeutic options can be made. (Crit Care Med 1998; 26:392‐408) In some intensive care units (ICUs), the measurement of a newly elevated temperature triggers an automatic order set which includes many tests that are time consuming, costly, and disruptive (Table 1). Moreover, the patient may experience discomfort, be exposed to unneeded radiation, or experience considerable blood loss due to this testing, which is often repeated several times within 24 hrs, and daily thereafter. In an era when utilization of hospital and patient resources is under intensive scrutiny, it is appropriate to assess how such fevers should be evaluated in a prudent and cost‐effective manner. Table 1. Typical costs associated with fever evaluation The American College of Critical Care Medicine of the Society of Critical Care Medicine and the Infectious Disease Society of America established a Task Force to provide practice parameters for the evaluation of a new fever in patients in an ICU with the goal of promoting the rational consumption of resources and promoting an efficient evaluation. These practice parameters presume that any unexplained temperature elevation merits a clinical assessment by a healthcare professional that includes a review of the patients history and a focused physical examination before any laboratory tests or imaging procedures are ordered. These practice parameters specifically address how to evaluate a new fever in an adult patient already in the ICU who has previously been afebrile and in whom the source of fever is not initially obvious. If the initial evaluation of history and physical examination reveals a consolidated lung, a purulent wound, or a phlebitic leg, then diagnosis and therapy of that infectious process should commence: such management is addressed by other practice parameters aimed specifically at pneumonia, catheter‐related infections, etc. Specific questions addressed in these practice parameters relate to the search for the underlying cause of fever and include: a) What temperature should elicit an evaluation? b) When are blood cultures warranted? c) When should intravascular catheters be cultured or removed? d) When are cultures of respiratory secretions, urine, stool, or cerebral spinal fluid warranted? e) When are radiographic studies warranted? These practice parameters do not address children, since children have different issues that merit discussion in a separate document. In addition, these practice parameters do not address an approach to persistent fever after the initial evaluation, or to localized infection once the anatomic source of fever has been identified. These issues are addressed in other monographs or practice parameters. The current document also does not address the desirability or selection of empiric vs. specific therapy since the need for therapy is so dependent on clinical evaluation and the underlying disease. It did not appear to this task force that useful therapeutic guidelines could easily be provided which took into account the acuity of illness, the underlying disease process, concurrent drugs (i.e., immunosuppressive agents, and antimicrobials), ability to tolerate toxicities, and geographic antibiotic susceptibility differences. Each ICU must establish its own policies for evaluating fever that take into account the type of ICU involved (e.g., medical ICU, surgical ICU, burn ICU, etc.), the specific patient population (e.g., immunosuppressed vs. immunocompetent, elderly vs. younger adults), recent epidemics (e.g., out‐breaks of Clostridium difficile diarrhea or vancomycin‐resistant Enterococcus), or endemic pathogens (e.g., methicillin‐resistant Staphylococcus aureus). It is hoped that these practice parameters will assist intensivists and consultants as a starting point for developing an effective and cost conscious approach appropriate for their patient populations. The specific recommendations are rated by the strength of evidence, using the published criteria of the Society of Critical Care Medicine (Table 2). Table 2. Society of Critical Care Medicines rating system for strength of recommendation and quality of evidence supporting the references

Utilization and diagnostic yield of blood cultures in a surgical intensive care unit

OBJECTIVE To evaluate the diagnostic yield of blood cultures obtained in a surgical intensive care unit (ICU) and to assess factors potentially influencing yield. DESIGN Retrospective, descriptive study. SETTING Surgical ICU in a university hospital. SUBJECTS All patients who had a blood culture obtained during their admission to the trauma/neurosurgical ICU of Presbyterian University Hospital from January 1, 1993 to December 31, 1993. MEASUREMENTS AND MAIN RESULTS Blood culture isolates were categorized as pathogens or contaminants and overall diagnostic yield was determined. Blood cultures were positive for pathogens in 4.6% of all culture episodes, while contaminants were isolated in 5.5% of all culture episodes. A total of 23 true bacteremias were identified in 21 patients, for an overall rate of bacteremia of 3.6 per 100 admissions (5.9 per 1,000 patient days). Concurrent antibiotics were being used at the time of blood culture in 65.3% of all culture episodes. The yield for pathogens was significantly lower (2.2%) when cultures were obtained on antibiotics compared with culture episodes obtained off antibiotics (6.4%) (p < .05). Single-set blood culture episodes were obtained in approximately 32% of all culturing episodes with the overall yield for pathogens of these culturing episodes lower (2.9%) than that of multiple-set culture episodes (5.3%) (p = NS). CONCLUSIONS Blood culture yield in this surgical ICU was relatively low in comparison with other published studies. The data further suggest that concurrent use of systemic antibiotics and inappropriate or excessive culturing may negatively influence blood culture yield.

Real-World Experience with Echinocandin MICs against Candida Species in a Multicenter Study of Hospitals That Routinely Perform Susceptibility Testing of Bloodstream Isolates

ABSTRACT Reference broth microdilution methods of Candida echinocandin susceptibility testing are limited by interlaboratory variability in caspofungin MICs. Recently revised Clinical and Laboratory Standards Institute (CLSI) breakpoint MICs for echinocandin nonsusceptibility may not be valid for commercial tests employed in hospital laboratories. Indeed, there are limited echinocandin susceptibility testing data from hospital laboratories. We conducted a multicenter retrospective study of 9 U.S., Australian, and New Zealand hospitals that routinely tested Candida bloodstream isolates for echinocandin susceptibility from 2005 to 2013. Eight hospitals used Sensititre YeastOne assays. The Candida spp. were C. albicans (n = 1,067), C. glabrata (n = 911), C. parapsilosis (n = 476), C. tropicalis (n = 185), C. krusei (n = 104), and others (n = 154). Resistance and intermediate rates were ≤1.4% and ≤3%, respectively, for each echinocandin against C. albicans, C. parapsilosis, and C. tropicalis. Resistance rates among C. glabrata and C. krusei isolates were ≤7.5% and ≤5.6%, respectively. Caspofungin intermediate rates among C. glabrata and C. krusei isolates were 17.8% and 46.5%, respectively, compared to ≤4.3% and ≤4.4% for other echinocandins. Using CLSI breakpoints, 18% and 19% of C. glabrata isolates were anidulafungin susceptible/caspofungin nonsusceptible and micafungin susceptible/caspofungin nonsusceptible, respectively; similar discrepancies were observed for 38% and 39% of C. krusei isolates. If only YeastOne data were considered, interhospital modal MIC variability was low (within 2 doubling dilutions for each agent). In conclusion, YeastOne assays employed in hospitals may reduce the interlaboratory variability in caspofungin MICs against Candida species that are observed between reference laboratories using CLSI broth microdilution methods. The significance of classifying isolates as caspofungin intermediate and anidulafungin/micafungin susceptible will require clarification in future studies.

MYROIDES INFECTION IN A BABOON AFTER PROLONGED PIG KIDNEY GRAFT SURVIVAL.

Background Immunosuppressed patients and experimental nonhuman primates are at risk of opportunistic infection. We report a Myroides spp. infection in an immunosuppressed baboon that had received a life-supporting kidney from a genetically engineered pig. Case Report The baboon received a costimulation blockade-based immunosuppressive regimen as well as 2 anti-inflammatory agents (tocilizumab and etanercept). Although the pig kidney functioned well, approximately 4 months after the transplantation, the baboon became less active and ate and drank poorly. On day 136, it collapsed and died despite inotropic and fluid support. A blood culture drawn before death grew Myroides spp. Discussion and Conclusions To our knowledge, Myroides spp. has not been reported as a cause of opportunistic infection in either patients with organ allotransplants or experimental animals. We summarize what is known about this rare organism and suggest it should be considered in any immunocompromised patient or animal. In the present case, we suggest the baboon died of circulatory shock following infection through an indwelling intravenous catheter.