TABLE 6.

Evaluation of fever in patients suspected of having ventilator-associated pneumonia

Clinical circumstanceManagement recommendation
Initial evaluation; clinically suspect VAPaCalculate day 1 CPIS (see Table 2); routine care for suspected VAP (see Table 3); if febrile, consider other etiologies (see Table 4)b; immediate institution of antimicrobial treatment after cultures performedc
Reevaluation at 48-72 hCalculate day 3 CPIS (see Table 2)
    (i) High likelihood of VAP (see Table 5) or (ii) nonpulmonary site
        of infection identified or (iii) unexplained severe sepsisdContinue antibiotics; adjust regimen based on culture results and probable site(s) of infectionb
    Chest X-ray infiltrates no longer presente; severe sepsis absent now
        and initially; no nonpulmonary site of infection identifiedDiscontinue antibiotics and follow patient; if still febrile, search for etiologyb
Non- or semiquantitative culture strategy
    (i) Day 1 CPIS of >6 and ETA culture positive or (ii) day 1 CPIS
        of ≤6 and day 3 CPIS of >6Continue antibiotics; adjust regimen based on culture results
    Day 1 CPIS of ≤6 and day 3 CPIS of ≤6 and:
        Cultures negative and antibiotics have not been changed or added
            in the 72 h prior to obtaining cultures (VAP unlikely)Discontinue antibiotics and follow patient; if still febrile, search for etiologyb
        (i) Cultures negative and antibiotics have been changed or added
            in the 72 h prior to obtaining cultures or (ii) cultures positiveNo firm recommendation; consider discontinuing antibiotics and following patientf (favored); if still febrile, search for etiologyb
    Day 1 CPIS of >6 and ETA culture negativeNo firm recommendation; consider discontinuing antibiotics and following if antibiotics have not been changed in the 72 h prior to obtaining cultures, particularly if alternative, noninfectious diagnosis confirmed; otherwise, continue antibiotics; if still febrile, search for etiologyb
Quantitative culture strategy
    Colony count exceeds threshold (VAP likely)gContinue antibiotics; adjust regimen based on culture results
    Colony count below threshold and:
        Antibiotics have not been changed or added in the 72 h prior
            to obtaining cultures (VAP unlikely)hDiscontinue antibiotics and follow patient; if still febrile, search for etiologyb
        Antibiotics have been changed or added in the 72 h prior
            to obtaining culturesNo firm recommendations; if still febrile, search for etiologyb
            Day 1 CPIS of ≤6 and day 3 CPIS of ≤6Consider discontinuing antibiotics and following patientf (favored)
            Factors increasing probability of true-negative result
                are presenthConsider discontinuing antibiotics and following patient
  • a CPIS on day 1 of >6 (see Table 2) and in the setting of ARDS, one or more of the following clinical parameters: new and persistent (>48 h) or progressive radiographic infiltrate, temperature of >38°C or <36°C, blood leukocyte count of >10,000 cells/ml or <5,000 cells/ml, purulent tracheal secretions, unexplained hemodynamic instability, or unexplained deterioration in oxygenation status.

  • b Consider that patient may have more than one explanation for fever.

  • c Rationale: delayed treatment of VAP increases mortality.

  • d Rationale: a definite site of infection cannot be found in 20 to 30% of patients with sepsis; delayed treatment of severe sepsis increases mortality.

  • e Rationale: infiltrates secondary to pneumonia do not improve in 72 h; consider atelectasis, congestive heart failure, hemorrhage, or chemical pneumonitis as the cause of pulmonary infiltrates.

  • f Rationale: based on reference 183.

  • g Factors increasing probability of a true-positive result: colony count more than 101 CFU/ml above threshold, presence of distal purulent secretions or persistence of distal secretions surging from distal bronchi during exhalation after bronchoscopic aspiration, >50% neutrophils on BAL, and >10% neutrophils and <1% epithelial cells on direct examination of BAL, PSB, or PTC.

  • h Factors increasing probability of a true-negative result: colony count more than 101 CFU/ml below threshold, absence of distal purulent secretions or persistence of distal secretions surging from distal bronchi during exhalation, <50% neutrophils on BAL differential, and <10% neutrophils and <1% epithelial cells on direct examination of BAL, PSB, or PTC.