Infectious Diseases in Critical Care Medicine

diagnostic possibilities have been eliminated in patients who have had a CVC in place for

days/weeks. Blood cultures should be obtained and the catheter removed for semiquantitative

culture of the CVC catheter tip. The finding of a positive catheter tip culture is one with 15

colonies plated in the method of Maki/Cleri. Positive catheter tip culture without bacteremia

indicates only a colonized catheter. Bacteremia without positive catheter tip culture with the

same organism indicates bacteremia but not secondary to the CVC. CVC related infections are

diagnosed by demonstrating the same organism in the blood and the catheter tip. The

treatment for CVC related infection is to remove the CVC. If no further central venous access is

necessary, the line may be discontinued, but if continued central IV line access is required, then

the catheter may be changed over a guidewire. Changing the catheter over a guidewire does

not subject the patient to the possibility of a pneumothorax from a subclavian insertion

(8,10,21,32,38,39).

Table 7 Clinical Features of Drug Fever

History

l Individuals often atopic

l Patients on a “sensitizing medication” for days or more commonly, months/years

Physical examination

l Low- to high-grade fevers (usually> 1028 F)

l Relative bradycardia (with temperature 1028 F){

l Patients appear “inappropriately well” for degree of fever (don’t look septica)

l No rashb

Laboratory tests

l Leukocytosis (with left shift)

l Eosinophils are usually present (eosinophilia is uncommon)

l Elevated ESR (may reach100 mm/h)

l Mildly elevated serum transaminases (early/transient)

aExcluding septic patients who also have drug fever.

bRash, if present, represents drug rash (not drug fever), which is usually accompanied

by fever. Drug rashes usually maculopapular (occasionally with a petechial component),

central, and may involve palms/soles.

{Excluding those onb-blockers, verapamil, or diltiazem.

Table 8 Causes of Drug Fever: Sensitizing Medications

Common Causes Uncommon Causes Rare Causes

Sulfa-containing drugs
Stool softeners (Colace)
Diuretics (Lasix)
Sleep medications
Antiseizure medications
Antidepressants/tranquilizers
Antiarrhythmics
NSAIDS
Antibiotics (b-lactams, sulfonamides)

All other medications Digoxin

Steroids

Diphenhydramine (Benadryl)

Aspirin

Vitamins

Aminoglycosides

Tetracyclines

Macrolides

Clindamycin

Chloramphenicol

Vancomycin

Aztreonam

Quinolones

Carbapenems

Tigecycline

Daptomycin

Quinupristin/dalfopristin

Linezolid

Abbreviation: NSAIDs, nonsteroidal anti-inflammatory drugs

Clinical Approach to Fever in Critical Care 11