Infectious Diseases in Critical Care Medicine

manipulation of a colonized/infected surface can induce a transient bacteremia. Such transient

bacteremias are unsustained and because of their short duration, i.e., less than five minutes,

they do not result in sustaining infection or spread infection to other organs, and for this

reason may not be treated. Single fever spikes of the transient bacteremias are a diagnostic not

a therapeutic problem. The other common cause of single fever spikes in the CCU is blood

product transfusions. Fever secondary to blood products/blood transfusions are a frequent

occurrence, and are most commonly manifested by fever following the infusion. The distribution

of fever is bimodal following a blood transfusion. Most reactions occur within the first 72 hours

after the blood/blood product transfusion, and most reactions within the 72-hour period occur in

the first 24 to 48 hours. There are very few reactions after 72 hours, but there is a smaller peak five

to seven days after the blood transfusion, which although very uncommon, may occur. The

temperature elevations associated with late blood transfusion reactions are lower than those with

reactions occurring soon after blood transfusion. The fever subsequent to the transient bacteremia

results from cytokine release and is not indicative of a prolonged exposure to the infecting agent,

but rather represents the post-bacteremia chemokine-induced febrile response. The temperature

Table 5 Clinical Applications of the “102 8 F Fever Rule” in the CCU

Common causes of fever< 1028 F Comments

Acute myocardial infarction l H/O chest pain/community-acquired pneumonia
l EKG/cardiac enzymes

Pulmonary embolism/infarction l H/O pulmonary emboli underlying reasons predisposing to
pulmonary emboli
l VQ scan positive (pulmonary angiography for large emboli)
l :FSPs with multiple small pulmonary emboli

GI bleed l Hyperactive bowel sounds, bleeding per rectum/melena
l :BUN (except in alcoholic liver disease)
l Endoscopy/abdominal CT scan?bleeding source

Acute pancreatitis l Severe abdominal pain: often associated with ARDS
l Grey–Turner’s/Cullen’s sign
l :Amylase and:lipase or pancreatitis on abdominal CT scan

Hematomas l H/O recent surgery/bleeding diathesis

Phlebitis l Local erythema without suppuration/vein tenderness

CAB l Bacteriuria and pyuria represents colonization, not infection
Bacteremia (urosepsis) does not result from bacteriuria unless there
is preexisting renal disease, urinary tract obstruction, or patient
has SLE, DM, steroids, etc.

Pleural effusions l Bilateral effusions are never due to infection: look for a noninfectious
etiology

Uncomplicated wound infections l Except for gas gangrene and streptococcal cellulitis, temperatures
are usually low grade
l “Wounds” with temperatures 1028 F should prompt a search for
an underlying abscess

Atelectasis/dehydration l Temperatures usually 1018 F
May be confused with pulmonary emboli/early pneumonia

Tracheobronchitis l Purulent endotracheal secretions with negative CXR
l Tracheobronchitis?temperatures< 1028 F

Thrombophlebitis l Warm, tender calf/foot veinspalpable cord
l Thrombophlebitis does not?pulmonary emboli
l Phlebothrombosis?pulmonary emboli

C. difficilediarrhea l Stools positive forC. difficiletoxin
l Fecal WBC positive*50%
l Temperatures< 1028 F

Abbreviations:ARDS, acute respiratory distress syndrome; BUN, blood urea nitrogen; CT, CAT scan; CAB,
catheter-associated bacteriuria; DM, diabetes mellitus; FSPs, fibrin split products; PE, pulmonary edema;
SLE, systemic lupus erythematosus.

Clinical Approach to Fever in Critical Care 7