Systematic Literature Review of the Association of Fever and Elevated Temperature with Outcomes in Critically Ill Adult Patients

Although most commonly associated with infection, elevated temperature and fever also occur in a variety of critically ill populations. Prior studies have suggested that fever and elevated temperature may be detrimental to critically ill patients and can lead to poor outcomes, but the evidence surrounding the association of fever with outcomes is rapidly evolving. To broadly assess potential associations of elevated temperature and fever with outcomes in critically ill adult patients, we performed a systematic literature review focusing on traumatic brain injury, stroke (ischemic and hemorrhagic), cardiac arrest, sepsis, and general intensive care unit (ICU) patients. Searches were conducted in Embase® and PubMed® from 2016 to 2021, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, including dual-screening of abstracts, full texts, and extracted data. In total, 60 studies assessing traumatic brain injury and stroke (24), cardiac arrest (8), sepsis (22), and general ICU (6) patients were included. Mortality, functional, or neurological status and length of stay were the most frequently reported outcomes. Elevated temperature and fever were associated with poor clinical outcomes in patients with traumatic brain injury, stroke, and cardiac arrest but not in patients with sepsis. Although a causal relationship between elevated temperature and poor outcomes cannot be definitively established, the association observed in this systematic literature review supports the concept that management of elevated temperature may factor in avoidance of detrimental outcomes in multiple critically ill populations. The analysis also highlights gaps in our understanding of fever and elevated temperature in critically ill adult patients.

Are corticosteroids or end-stage renal failure associated with an afebrile presentation of Gram-negative bacteraemia?

OBJECTIVES

Assertions regarding afebrile presentation of sepsis frequently lead to superfluous antibiotic treatment. This study aimed to identify the risk factors for afebrile presentation of bacteraemia, focusing on glucocorticoid (GC) treatment and end-stage renal disease (ESRD).

METHODS

This retrospective cohort study included all patients with bacteraemia caused by common Gram-negative bacteria in one hospital. The exposure variables were GC treatment, administered for at least 48 hours before bacteraemia onset, and ESRD, defined as patients undergoing dialysis. Risk factors were assessed for afebrile presentation, defined as temperature between 36.0-37.7°C for all measurements, 48 hours prior to blood culture collection. Analyses were subgrouped by community-onset and hospital-acquired Gram-negative bacteraemia (GNB). Propensity score (PS)-weighted multivariate analyses were conducted.

RESULTS

Of 4179 patients with GNB, 1090 (26.1%) presented without fever before blood culture collection. In community-onset GNB, GC treatment was significantly associated with afebrile presentation, PS-weighted OR 1.42 (95% CI 1.25-1.61), absolute risk increase 7% (95% CI 4.3-9.8%), while ESRD was not. For hospital-acquired GNB, ESRD was significantly associated with afebrile presentation (OR 1.53; 95% CI 1.25-1.86; absolute risk increase 8.5%; 95% CI 4.4-13.1%); GC was not. Other risk factors for afebrile presentation in both subgroups included increasing Charlson comorbidity score, bacteraemia with non-fermenters Pseudomonas aeruginosa or Stenotrophomonas maltophilia (compared with Enterobacteriaceae), and lower albumin levels. Aging was not associated with afebrile presentation of GNB.

CONCLUSION

Although significant associations between GC and ESRD and afebrile presentation of GNB were observed, they were different in community-onset and hospital-acquired GNBs, and absolute risk increases were small.

Incidental detection of Corynebacterium jeikeium endocarditis via regular blood examination in an afebrile hemodialysis patient

Herein, we describe a rare case of Corynebacterium jeikeium endocarditis that silently progressed in a 65-year-old man undergoing hemodialysis. Because routine monthly blood examination revealed high C-reactive protein levels, blood cultures were collected, although he had no symptom and was afebrile. After 2 days, a Gram-positive rod was detected in one set of the blood culture. Furthermore, transthoracic echocardiography revealed new aortic regurgitation (AR) and vegetations, and, therefore, infective endocarditis was suspected. Transesophageal echocardiography showed vegetations with a maximum diameter of 8 mm on his aortic valve, with some valve destruction. C. jeikeium was identified in three sets of blood cultures. Administration of daptomycin was started because he had vancomycin allergy. Judging from the high risk of embolization due to vegetations, emergency aortic valve replacement was performed on the second day. C. jeikeium was detected in a resected cardiac valve specimen and blood. This case emphasizes that physicians should always consider the possibility of infective endocarditis even in hemodialysis patients without any symptoms.

Do Bacteremic patients with end-stage renal disease have a fever when presenting to the emergency department? A paired, retrospective cohort study

Background

Fever is a common symptom when patients present to Emergency Departments. It is unclear if the febrile response of bacteremic hemodialysis-dependent patients differs from bacteremic patients not receiving hemodialysis. The objective of this study was to compare Emergency Departments triage temperatures of patients with and without hemodialysis-dependent end-stage rental disease who have Staphylococcus aureus bacteremia and determine the incidence of afebrile S. aureus bacteremia.

Methods

Paired, retrospective cohort study of 37 patients with and 37 patients without hemodialysis hospitalized with Methicillin-resistant or Methicillin-susceptible S. aureus bacteremia. Emergency Department triage temperatures were reviewed for all patients, as were potential confounding variables.

Results

54% (95% CI, 38–70%) and 82% (95% CI 65–91%) of hemodialysis and non-hemodialysis patients did not have a detectable fever (<100.4 °F) at triage. Triage temperatures were 100.5 °F (95% CI 99.9–101.2 °F) and 99.0 °F (95% CI 98.4–99.6 °F) in the hemodialysis and non-hemodialysis cohorts, respectively (p < 0.001). Triage temperature in patients with and without diabetes mellitus was 99.2 °F (95% CI 98.4–99.9 °F) and 100.4 °F (95% CI 99.7–101.0 °F), respectively (p = 0.03). We were unable to detect a significant effect of diabetes mellitus and other potential confounding variables on differences in temperature between the hemodialysis and non-hemodialysis cohorts (all interactions p > 0.19).

Conclusions

Hemodialysis-dependent patients with S. aureus bacteremia had significantly higher temperatures than non- hemodialysis-dependent end stage renal disease patients but more than half of patients were without detectable fever at triage, possibly reflecting use of insensitive methods for measuring temperature. Absence of fever at presentation to the Emergency Department should not delay blood culture acquisition in patients who are at increased risk of S. aureus bacteremia.

Chronic dialysis patients with infectious spondylodiscitis have poorer outcomes than non-dialysis populations

Purpose

Infectious spondylodiscitis is a serious disease that can lead to permanent neurological deficit. Because there were only a few case reports or series featuring infectious spondylodiscitis in chronic dialysis patients, we investigated the epidemiology and outcome in the chronic dialysis patients versus general population.

Materials and methods

We retrospectively identified chronic dialysis patients admitted for infectious spondylodiscitis between January 2002 and December 2015. A total of 105 chronic dialysis patients were included, and we performed a 1:2 case-control match on propensity score in non-dialysis patients with infectious spondylodiscitis. The demographic features, clinical manifestation, infection focus, and disease outcome were recorded.

Results

A total of 302 patients entered the final analysis. Chronic dialysis patients less frequently had fever (34.3%), and in the majority, bacterial entry was through dialysis vascular access (30.5%). Methicillin-resistant Staphylococcus aureus (MRSA) comprised the majority of causative pathogen. The chronic dialysis group had longer hospital stay, higher in-hospital mortality, and higher 1-year mortality. The odds ratio of in-hospital mortality was 2.20 compared with the non-dialysis group.

Conclusions

The study highlighted poorer outcome and high frequency of resistant Staphylococcus of infectious spondylodiscitis in chronic dialysis patients. Therefore, high vigilance, prompt recognition, and empiric coverage of MRSA will be important in the management of infectious spondylodiscitis in chronic dialysis patients.