Critical Illness Leads to More Extensive Fever Work-up, but Consensus is Lacking

Author(s):
Patrick Delaplain; Jeffrey Santos; Justin Dvorak; Tina Mele; Rondi Gelbard; Christopher Guidry; Philip Barie; Sebastian Schubl

Background:

Despite the high prevalence of post-operative fever, consensus is lacking for the components of a fever work-up and when empiric antibiotics (abx) should be started.

Hypothesis:

There is a lack of consensus surrounding many common components of a post-operative fever work-up.

Methods:

Surgical Infection Society membership surveyed to determine practices surrounding post-operative fever work-up. Eight scenarios were posed in febrile (38.5°C), post-op general surgery (GS) or trauma (T) pts with 19 possible components of work-up (physical exam, CBC, fungal biomarkers, lactate, procalcitonin [PCT], cultures [cx], imaging) and management (abx). Each scenario was then reconsidered for ICU pts (intubated/hemodynamically unstable). Agreement on a parameter (< 1/3 or > 2/3 of respondents) achieved consensus, positive or negative. Parameters between had equipoise. Comparisons between averaged percentage of respondents is done with Wilcoxon test.

Results:

The distribution of responses was similar between non-ICU GS and T patients, although the averaged % respondents who chose CBC and PCT was higher in GS patients (90% vs. 82%, p=0.019 and 23% vs. 18%, p=0.025). Across non-ICU GS and T scenarios, only physical exam (91%) and CBC (87%) achieved positive consensus. There was no consensus for blood cx (53%), urine cx (50%), CXR (65%) or empiric abx (Gram + [36%], Gram – [37%]). All other work-up components achieved negative consensus. Summarized averaged responses (n = 47) between ICU and non-ICU scenarios are shown below (Figure.) For ICU scenarios, there were no differences among parameters that achieved consensus (GS vs. T.) Physical exam (92%), CBC (91%), blood cx (70%), CXR (81%), and abx (Gram+ [68%], Gram- [69%]) achieved positive consensus. There was equipoise for PCT, lactate, urine cx, CT abdomen, and bronchoscopy/lavage.

Figure. Percentage of respondents selecting individual elements of a fever work-up across ICU and non-ICU scenarios.

Conclusions:

The initial operation had minimal impact on selected fever work-up among respondents. However, higher acuity (i.e., ICU scenarios) led to more components achieving positive consensus. Parameters with equipoise are potential candidates for formal guidance or pragmatic prospective trials.