COMMON DIAGNOSTIC PROBLEMS IN THE CCU
Drug Fever
Drug fevers are so important in the CCU setting because of the multiplicity of medications.
Physicians should always be suspicious of the possibility of drug fever when other diagnostic
possibilities have been exhausted. Drug fever may occur in individuals who have just recently
been started on the sensitizing medication, or more commonly who have been on a sensitizing
medication for a long period of time without previous problems. Patients with drug fever do
not necessarily have multiple allergies to medications and are not usually atopic. However, the
likelihood of drug fever is enhanced in patients who are atopic with multiple drug allergies.
Table 6 Clinical Applications of the “102 8 F Rule” in the CCU
Common causes of fever> 1028 F Comments
NP/VAP l Temperatures usually 1028 F
l Pulmonary infiltrate consistent with a bacterial pneumonia
occurring>5 days after hospitalization
l NP/VAP must be differentiated on CXR from ARDS, LVF, etc.
l Endotracheal secretion isolates represent upper airway
colonization and are not reflective of lower respiratory tract
organisms causing VAP
l Endotracheal respiratory secretion isolates should not be
“covered” with empiric antibiotics
Central venous catheter (CVC) infections l Usually CVCs in for>7 days
l Organisms from blood cultures taken from noninvolved
extremity same as positive semiquantitative catheter tip
culture (15 colonies)
l If all other sources of fever are ruled out, consider CVC
infection, especially with lines in for>7 days (even if site
not infected visually)
Septic thrombophlebitis l Pus at CVC insertion site after CVC removal
l Temperatures usually> 1028 F
l Blood cultures positive
C. difficilecolitis l Stools positive forC. difficiletoxin
l Abrupt:WBC count to 30–50 k/mm^3
l Abrupt cessation of diarrhea in a patient withC. difficilediarrhea
l New abdominal pain in patient withC. difficilediarrhea
l Abdominal CT scan shows colonic ‘thumbprinting”/pancolitis/
toxicmegacolon
Drug fever l Consider drug fever in patients with otherwise unexplained
temperatures
l Blood cultures are negative (excluding contaminants)
l Patients with drug fever usually have 1028 F with relative
bradycardiaa
l :WBC with left shift
l Mild/moderate serum transaminases
l Eosinophils present (eosinophilia less commonly)
l :ESR
l Commonest causes of drug fever are diuretics, pain/sleep
medications, sulfa-containing stool softeners/drugs or
b-lactam antibiotics (see Table 6)
Blood/blood product transfusion l Single fever spike (1–3 or 5–7 days posttransfusion)
Transient bacteremia due to
manipulation of a colonized/infected
mucosal surface
l Single temperature spike 1–3 days, postmanipulative, that
spontaneously resolves without treatmentSerious systemic infectious diseases l Most normal hosts have fevers 1028 F
aPatients without heart block/arrhythmias, pacemaker rhythm, or onb-blockers, diltiazem, or verapamil
Abbreviations: BBB, bundle branch block; BAL, bronchioalveolar lavage; CT, CAT scan; CVC, central venous catheter;
ESR, erythrocyte sedimentation rate; NP, nosocomial pneumonia; VAP, ventilator-associated pneumonia
Clinical Approach to Fever in Critical Care 9