Clinical and Demographic Factors Associated with Antipyretic Use in Gram-Negative Severe Sepsis and Septic Shock

Abstract

Background Antipyretic therapy is commonly prescribed to patients with infection, but its impact on clinical outcomes has yielded mixed results. No data currently exist to characterize the use of antipyretic medications in patients with severe sepsis or septic shock. Objective We sought to identify clinical and demographic factors associated with antipyretic medication administration in severe sepsis and septic shock. Methods Single-center retrospective cohort study of all febrile patients (Tmax ≥ 38.3°C) at a 1,111-bed academic medical center with gram-negative severe sepsis or septic shock between January 2002 and February 2008. Patients were excluded for liver disease, acute brain injury, and allergy to acetaminophen. Generalized estimating equations were used to estimate the effect of clinical factors on treatment of patients with antipyretic medications. Results Although 76% of patients in this febrile cohort (n = 241) had an order for an antipyretic agent, only 42% received antipyretic therapy and 95% of antipyretic doses were acetaminophen. Variables associated with antipyretic treatment were temperature (OR 2.11/°C, 1.53 – 2.89), time after sepsis diagnosis (OR 0.88/8 hrs, 0.82 – 0.95), surgery during hospitalization (OR 0.49, 0.31 – 0.80), death within 36 hours (OR 0.35, 0.15 – 0.85), and mechanical ventilation (OR 0.58, 0.34 – 0.98). Conclusions Most febrile episodes in patients with gram-negative severe sepsis or septic shock were not treated with antipyretic medications. Treatment factors predicted antipyretic therapy, but severity of illness factors, demographic factors, and location in the hospital did not.

Correlation Between Body Temperature and Survival Rate in Patients With Hospital-Acquired Bacteremia

“…There are conflicting findings regarding the relationship of antipyretic use to mortality in febrile patients with sepsis, and there are no directly comparable study designs. In general, our findings are consistent with those of a retrospective study by Mohr et al (2011) of early exposure to antipyretics in patients with severe sepsis or septic shock. The researchers found that use of antipyretics within 4 hr before to 6 hr after blood culture collection was not associated with increased mortality when compared to those without exposure to antipyretics within that time frame.…”

“…They found no significant association between the use of antipyretics and mortality in febrile subjects without sepsis. Despite their widespread use, there is still insufficient evidence on the risks and benefits of fever suppression with antipyretics in patients with bacteremia, and standards of practice are lacking (Mohr et al, 2011;Niven et al, 2012).…”

“…Evidence of the benefits or harms of fever suppression with antipyretics in patients with bacteremia remains inconclusive. However, it is still a common practice for physicians to write conditional orders (also known as PRN orders meaning ''when needed'') for antipyretics to be administered to reduce fever, often without a defined temperature threshold (Mohr et al, 2011;Niven et al, 2012;Schulman et al, 2005). Despite the limitations in our understanding of fever pathophysiology and the effects on survival of exogenous antipyretics, nurses have primary responsibility for monitoring patients' temperatures and implementing PRN orders to treat fever.…”

Respective impact of lowering body temperature and heart rate on mortality in septic shock: mediation analysis of a randomized trial

“…Fever is a very common symptom and antipyretics are widely used in the ICU [3,6,28,29]. Many questions about the consequences of fever remain unresolved.…”

A Comparative Study on Predictive Validity of Modified Shock Index, Shock Index, and Age Shock Index in Predicting the Need for Mechanical Ventilation among Sepsis Patients in a Tertiary Care Hospital

“…[ 8 ] One of the common presenting symptoms in triage is fever which is seen in many spectra of diseases; however, it is the main clue in clenching diagnosis in 55%–76% of sepsis patients. [ 9 , 10 ] The signs of sepsis is not easily distinguishable from other uncomplicated febrile illness as it is very subtle, and not specific. Sepsis is difficult to diagnose in triage and the emergency department where time is a main constraint.…”