Internal Medicine Services, National Institutes of Health Clinical Center, Bethesda, MD.
Clinical Pharmacy Services, Department of Pharmacy, Tampa General Hospital, Tampa, FL.
Crit Care Med. 2023 Nov 1;51(11):1570-1586. doi: 10.1097/CCM.0000000000006022. Epub 2023 Oct 12.
Fever is frequently an early indicator of infection and often requires rigorous diagnostic evaluation.
This is an update of the 2008 Infectious Diseases Society of America and Society (IDSA) and Society of Critical Care Medicine (SCCM) guideline for the evaluation of new-onset fever in adult ICU patients without severe immunocompromise, now using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology.
The SCCM and IDSA convened a taskforce to update the 2008 version of the guideline for the evaluation of new fever in critically ill adult patients, which included expert clinicians as well as methodologists from the Guidelines in Intensive Care, Development and Evaluation Group. The guidelines committee consisted of 12 experts in critical care, infectious diseases, clinical microbiology, organ transplantation, public health, clinical research, and health policy and administration. All task force members followed all conflict-of-interest procedures as documented in the American College of Critical Care Medicine/SCCM Standard Operating Procedures Manual and the IDSA. There was no industry input or funding to produce this guideline.
We conducted a systematic review for each population, intervention, comparison, and outcomes question to identify the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the GRADE approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak or as best-practice statements.
The panel issued 12 recommendations and 9 best practice statements. The panel recommended using central temperature monitoring methods, including thermistors for pulmonary artery catheters, bladder catheters, or esophageal balloon thermistors when these devices are in place or accurate temperature measurements are critical for diagnosis and management. For patients without these devices in place, oral or rectal temperatures over other temperature measurement methods that are less reliable such as axillary or tympanic membrane temperatures, noninvasive temporal artery thermometers, or chemical dot thermometers were recommended. Imaging studies including ultrasonography were recommended in addition to microbiological evaluation using rapid diagnostic testing strategies. Biomarkers were recommended to assist in guiding the discontinuation of antimicrobial therapy. All recommendations issued were weak based on the quality of data.
The guidelines panel was able to formulate several recommendations for the evaluation of new fever in a critically ill adult patient, acknowledging that most recommendations were based on weak evidence. This highlights the need for the rapid advancement of research in all aspects of this issue-including better noninvasive methods to measure core body temperature, the use of diagnostic imaging, advances in microbiology including molecular testing, and the use of biomarkers.
发热通常是感染的早期指标，往往需要严格的诊断评估。
这是对 2008 年美国传染病学会（IDSA）和危重病医学会（SCCM）成人 ICU 新发发热患者评估指南的更新，现在使用推荐评估、制定和评估（GRADE）方法。
SCCM 和 IDSA 召集了一个工作组，更新 2008 年版的危重病成人新发发热患者评估指南，其中包括来自重症监护、发展和评估小组指南的专家临床医生以及方法学家。指南委员会由 12 名重症监护、传染病、临床微生物学、器官移植、公共卫生、临床研究和卫生政策与管理方面的专家组成。所有工作组的成员都遵循了美国危重病医学会/SCCM 标准操作程序手册和 IDSA 中记录的所有利益冲突程序。没有工业投入或资金来制定本指南。
我们对每个人群、干预、比较和结果问题进行了系统评价，以确定最佳可用证据，对证据进行统计总结，然后使用 GRADE 方法评估证据质量。我们使用证据决策框架制定了强烈或弱或最佳实践声明的建议。
小组发布了 12 项建议和 9 项最佳实践声明。小组建议使用中央温度监测方法，包括肺动脉导管、膀胱导管或食管球囊热敏电阻器中的热敏电阻器，如果这些设备已经就位或准确的温度测量对诊断和管理至关重要。对于没有这些设备的患者，建议使用口腔或直肠温度测量方法，而不是不太可靠的其他温度测量方法，如腋窝或鼓膜温度测量、非侵入性颞动脉温度计或化学点温度计。建议除了使用快速诊断测试策略进行微生物学评估外，还进行影像学检查，包括超声检查。建议使用生物标志物协助指导抗菌治疗的停药。由于数据质量差，所有发布的建议均为弱。
指南小组能够为危重病成人新发发热患者的评估制定一些建议，承认大多数建议都是基于薄弱的证据。这突显了在这一问题的所有方面迅速推进研究的必要性，包括更好的非侵入性方法来测量核心体温、使用诊断影像学、在微生物学方面的进展，包括分子检测，以及使用生物标志物。
