. 2006 Oct;19(4):637–657. doi: 10.1128/CMR.00051-05

TABLE 6.

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

Clinical circumstance	Management recommendation
Initial evaluation; clinically suspect VAP^a	Calculate 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 performed^c
Reevaluation at 48-72 h	Calculate 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 sepsis^d	Continue antibiotics; adjust regimen based on culture results and probable site(s) of infection^b
Chest X-ray infiltrates no longer present^e; severe sepsis absent now
and initially; no nonpulmonary site of infection identified	Discontinue antibiotics and follow patient; if still febrile, search for etiology^b
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 >6	Continue 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 etiology^b
(i) Cultures negative and antibiotics have been changed or added
in the 72 h prior to obtaining cultures or (ii) cultures positive	No firm recommendation; consider discontinuing antibiotics and following patient^f (favored); if still febrile, search for etiology^b
Day 1 CPIS of >6 and ETA culture negative	No 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 etiology^b
Quantitative culture strategy
Colony count exceeds threshold (VAP likely)^g	Continue 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)^h	Discontinue antibiotics and follow patient; if still febrile, search for etiology^b
Antibiotics have been changed or added in the 72 h prior
to obtaining cultures	No firm recommendations; if still febrile, search for etiology^b
Day 1 CPIS of ≤6 and day 3 CPIS of ≤6	Consider discontinuing antibiotics and following patient^f (favored)
Factors increasing probability of true-negative result
are present^h	Consider discontinuing antibiotics and following patient

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.

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

Rationale: delayed treatment of VAP increases mortality.

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

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.

Rationale: based on reference 183.

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.

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.