Strategies for management of the febrile patient

Although infection is the most common cause of fever in critically ill patients, there are many other potential causes of fever and anti-infective therapy may not always be appropriate. Despite this, many clinicians would utilize a broad-spectrum antibiotic in such a patient if fever was sustained or severe (> 39 °C), once appropriate microbiological cultures had been taken. The choice of antibiotic should be guided by the nature of the underlying primary condition or any subsequent interventions and by knowledge of local antibiotic sensitivity patterns of common pathogens. A hierarchical approach may be appropriate, changing antibiotics after 48 to 72 h if there has been no response.

Central venous catheter infections become more common with increase of duration of use, and therefore some units have a policy of routine changes after a fixed period of time regardless of the presence or absence of signs of colonization or infection. If this is not the case, signs of sepsis in a patient whose catheters have been present for 72 h or more should prompt complete replacement or guide-wire exchange. Defervescence following such a maneuver suggests that the catheters were to blame.

It is not uncommon to encounter patients with persistent fever after several courses of broad-spectrum antibiotics in the absence of clear positive cultures. In this situation it may be appropriate, depending on the severity of the underlying condition, to discontinue antibiotics and repeat cultures after a 'diagnostic window' of 24 to 48 h. Pathogens partially susceptible to the prevailing antibiotic therapy may be impossible to culture in the presence of such treatment but may become apparent on cessation, or indeed the fever may remit as antibiotic drugs themselves are a not infrequent cause of fever as part of an allergic-type response. Similarly, other drugs may cause febrile reactions and it may be helpful to withdraw all drugs which may not be absolutely necessary during such a 'diagnostic window', particularly those known to be associated with febrile or allergic reactions.

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