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January 21st, 2013
Must-Read Piece: “Fever of Too Many Origins”
Every so often a commentary gets something just right, and fortunately we have an example in this week’s New England Journal of Medicine.
Entitled “Fever of Unknown Origin or Fever of Too Many Origins?”, it’s the best depiction I’ve read about doing ID consults in the intensive care unit (ICU). The author, Harold Horowitz (who has practiced ID in tertiary care hospitals for 3 decades), contrasts the classic Fever of Unknown Origin (FUO) with the arguably more common Fever of Too Many Origins (FTMO), which is all-too recognizable for those who do hospital-based patient care.
These are patients “who have traumatic brain injury, other neurologic events, or dementia; are mechanically ventilated; have some combination of urethral, central, and peripheral catheters placed; have recently undergone surgery; and are already receiving multiple broad-spectrum antibiotics.”
In other words, they might have originally had diverse medical and surgical problems, but they’ve now entered the narrow portion of the ICU funnel, and are strikingly similar.
There are many quotable passages, but the following is my favorite:
As the keeper of the antibiotics, should I be a conservative or a cowboy? Should the current antibiotics be continued, changed, or stopped? If there are no prescribed antibiotics, should I recommend some? These are interesting questions in the abstract, but there is a real patient suffering, a family with questions, and medical teams awaiting my opinion. There are no evidence-based studies and there is no guidance on which potential source of fever is the single appropriate one to treat. Frequently, the treatment approach is like playing Whac-A-Mole: positive cultures are treated sequentially — pneumonia, then catheter cultures, then urine cultures. When the fever persists, the cycle begins again.
Whac-a-Mole — what a great analogy! I’ve written before about my frustrations with ICU-related Infectious Diseases (here and here), but Horowitz does it better. I found myself nodding with recognition time and time again.
While the tone of the piece is understandably melancholy — these are patients not for ID case conference, but for “family conferences that include plans for palliative care” — I was left with a somewhat more hopeful thought. Namely, that once we recognize the eerie similarity of these ICU ID consults, then perhaps we can evaluate their optimal management in a controlled clinical trial. Something like this:
Inclusion criteria: ICU stay > 1 week; endotracheal intubation; fever > 101.5F; multiple possible sources of fever but no obvious single source (e.g. bacteremia).
Intervention: Randomization to one of two treatment strategies: 1) Initiate or change to empiric broad-spectrum antibiotcs with cessation after 3 days if cultures are unrevealing and there is no objective clinical improvement; or 2) Standard of care.
Primary endpoint: All-cause mortality.
Secondary endpoints: Infection-related mortality, length of ICU stay, antibiotic exposure, adverse effects of antibiotics (including C diff), bacterial resistance, fungal superinfection, cost, etc.
Primary funding source: The National Institutes of Allergy and Infectious Diseases.
Sure beats Whac-a-Mole.