Are we over-treating fever?

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By Chen, Leon MS, RN, AGACNP-BC, CCRN, CPEN

Nurse Practitioner, ICU – Memorial Sloan Kettering Cancer Center in NYC

“You took away her fever. You raised her spirit.” Those words echoed to the tune of soft pleasant music in the new Tylenol commercial. The uplifting, alleviating effect of antipyretics can be attested by many who have suffered from a fever at one point in their life. I still remember in simulation labs, we’re quizzed on the temperature considered to be febrile and our expected immediate follow-up answer of “I’ll administer some Tylenol”. Treating fevers has been drilled into our core medical knowledge. But in actuality, our ability to mount a fever stem from an evolutionary need to survive from an infection and to take it away may not be beneficial.

Our body’s ability to generate heat actually produces a hostile environment for bacterial growth. In vitro studies have shown that pathogen growth is stunted at a core temperature above 37 degrees Celsius. (1) In clinical studies, the patients who are able to generate a febrile response have been associated with lower risk of mortality. (2)(3) Of course, fever has its downsides, including increasing metabolic demand, oxygen demand and in children, potential febrile seizures. So what are we to do? Do we treat the fever or do we not treat the fever? And what do we do about fever in the ICU population? To help us answer the question, the Acetaminophen for Fever in Critically Ill Patients with Suspected Infection study (HEAT trial) has just been published by New England Journal of Medicine. In the study, researchers randomized 700 ICU patients with fever (body temperature>38 degrees Celsius) to either receiving IV Tylenol or placebo every 6 hours until ICU discharge, resolution of fever, cessation of antibiotics, or death. The primary outcome was ICU-free days from randomization to day 28 on follow-up.delete

The result of this study showed that early administration of Tylenol to treat fever due to probably infection had no effect on the number of ICU-free days. (4)This study adds on to the increasing number of negative trials showing that less intervention or more conservative management strategies are acceptable and does not cause harm. Given that ICU patients are already at risk for organ dysfunction in the setting of polypharmacy and their critical illness, I hesitate to further burden their system with Tylenol. Therefore, in patients with suspected infection, antibiotic is the ultimate treatment and antipyretics should only be an afterthought.

References

  1. Prescott, Lansing M, John P. Harley, Donald A. Klein, Gloria Delisle, and Lewis Tomalty. Microbiology. Boston, Mass: WCB/McGraw-Hill, 1999. Print
  2. Weinstein MP, Iannini PB, Stratton CW, Eickhoff TC. Spontaneous bacterial peritonitis. A review of 28 cases with emphasis on improved survival and factors influencing prognosis. Am J Med. 1978 Apr;64(4):592-8.
  3. Ahkee S, Srinath L, Ramirez J. Community-acquired pneumonia in the elderly: association of mortality with lack of fever and leukocytosis. South Med J. 1997 Mar;90(3):296-8.
  4. Young et al. Acetaminophen for Fever in Critically Ill Patients with Suspected Infection. N Engl J Med. 2015 Oct 5. [Epub ahead of print]
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