The degree of chills for risk of bacteremia in acute febrile illness

doi:10.1016/j.amjmed.2005.06.043

The American Journal of Medicine

Volume 118, Issue 12, December 2005, Pages 1417.e1-1417.e6

https://doi.org/10.1016/j.amjmed.2005.06.043 Get rights and content

Abstract

Purpose

Patients with acute febrile illness may experience different degrees of chills. To evaluate the different degrees of chills in predicting risk of bacteremia in patients with acute febrile illness, we performed a single-center prospective observational study.

Methods

We enrolled consecutive adult patients with acute febrile illness presenting to our emergency department. We defined mild chills as cold-feeling equivalent such as the need of an outer jacket; moderate chills as the need for a thick blanket; and shaking chills as whole-body shaking even under a thick blanket. We estimated risk ratios of the different degrees of chills for bacteremia using multivariable adjusted Poisson regression.

Results

Of a total 526 patients, 40 patients (7.6%) had bacteremia. There were 65 patients (12.4%) with shaking chills, 100 (19%) with moderate chills, and 105 (20%) with mild chills. By comparing patients with no chills, the risk ratios of bacteremia were 12.1 (95% confidence interval [CI] 4.1-36.2) for shaking chills, 4.1 (95% CI 1.6-10.7) for moderate chills, and 1.8 (95% CI 0.9-3.3) for mild chills. Shaking chills showed a specificity of 90.3% (95% CI 89.2-91.5) and positive likelihood ratio of 4.65 (95% CI 2.95-6.86). The absence of chills showed a sensitivity of 87.5% (95% CI 74.4-94.5) and negative likelihood ratio of 0.24 (95% CI 0.11-0.51).

Conclusion

Evaluation of the degree of chills is important for estimating risk of bacteremia in patients with acute febrile illness. The more severe degree of chills suggests the higher risk of bacteremia.

Section snippets

Patient assembly and data collection

In our prospective observational study, we enrolled consecutive patients (aged 15 years and older) who presented with acute febrile illness and were admitted to the emergency department of Okinawa Chubu Hospital, Japan. The hospital is a major community hospital and provides primary and specialty care to a population of approximately 400 000. Patient enrollment was from 2 periods (May to July and January to March) to include both summer and winter seasons.

The patient inclusion criteria were all

Statistical analysis

We used risk ratios as the primary measure of association for bacteremia of patients with different degrees of chills in reference to patients with no chills. We estimated risk ratios by multivariable Poisson regression rather than by using logistic regression in which odds ratio may overestimate true relative risk when analyzing common outcome.²⁵ Risk ratio is also easier to understand for a nonepidemiologist than odds ratio.²⁶ Additionally, we determined statistical characteristics such as

Results

We enrolled and analyzed a total of 526 consecutive febrile emergency department patients. Mean age was 57 years (range 15-106) and 248 (47%) were men. Table 1 shows the clinical characteristics for each degree of chills and total patients. Of 526 patients, 256 patients had no chills (48.7%; 95% confidence interval [CI] 44.3-53.0%); 105 patients had mild chills (20.0%; 95% CI 16.6-23.6%); 100 patients had moderate chills (19.0%; 95% CI 15.8-22.6%); and 65 patients had shaking chills (12.4%; 95%

Discussion

Our study showed that the increased degrees of chills indicated a higher risk of bacteremia in patients with acute febrile illness. Particularly, patients with shaking chills had the greatest risk of bacteremia. Our data highlight the prudent use of qualitative chill degrees when interviewing patients with acute febrile illness. We may need to elicit a more precise focus on this useful component of clinical history. Moreover, the diligent observant medical interview has minimal cost while it

Acknowledgment

We thank Mrs. Tomoko Yonaha for her excellent secretarial support.

References (32)

J.A. Washington et al.
Blood culturesissues and controversies
Rev Infect Dis.
(1986)
R.C. Bone et al.
Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine
Chest
(1992)
P.H. Chandrasekar et al.
Clinical issues of blood cultures
Arch Intern Med.
(1994)
M.D. Aronson et al.
Blood cultures
Ann Intern Med.
(1987)
L. Leibovici et al.
Bacteremia in febrile patients. A clinical model for diagnosis
Arch Intern Med.
(1991)
P.B. Fontanarosa et al.
Difficulty in predicting bacteremia in elderly emergency patients
Ann Emerg Med.
(1992)
B. Mozes et al.
Inconsistency of a model aimed at predicting bacteremia in hospitalized patients
J Clin Epidemiol.
(1993)
D.W. Bates et al.
Predicting bacteremia in hospitalized patients. A prospectively validated model
Ann Intern Med.
(1990)
P. Peduzzi et al.
Predictors of bacteremia and gram-negative bacteremia in patients with sepsis
Arch Intern Med.
(1992)
D.W. Bates et al.
Predicting bacteremia in patients with sepsis syndrome
J Infect Dis.
(1997)

J.M. Mylotte et al.

Validation of a bacteremia prediction model

Infect Control Hosp Epidemiol.

(1995)

C. Chirouze et al.

Low serum procalcitonin level accurately predicts the absence of bacteremia in adult patients with acute fever

Clin Infect Dis.

(2002)

H. Aalto et al.

Laboratory markers of systemic inflammation as predictors of bloodstream infection in acutely ill patients admitted to hospital in medical emergency

Eur J Clin Microbiol Infect Dis.

(2004)

M. von Lilienfeld-Toal et al.

Markers of bacteremia in febrile neutropenic patients with hematological malignanciesprocalcitonin and IL-6 are more reliable than C-reactive protein

Eur J Clin Microbiol Infect Dis.

(2004)

W.G. Rector

Fever, shock and chills in gram-negative bacillemiaclinical correlations in 100 cases

Johns Hopkins Med J.

(1981)

J.T. Van Dissel et al.

Implications of chills

Lancet.

(1998)

Cited by (46)

Atypical Presentation of Bacteremia in Older Patients Is a Risk Factor for Death
2019, American Journal of Medicine
The absence of fever in bacteremia in patients who are older is known to delay diagnosis. Our objective was to determine whether atypical presentation was associated to mortality as a result of bacteremia in this patient cohort as well as possible factors associated with this atypical presentation.
We conducted an observational prospective study in 2 French university hospitals in 2016-2017 including patients ages ≥ 75 years with bacteremia. Atypical presentation was defined as the absence of a temperature ≥ 38.3°C or < 36°C, chills, or hypotension. Mortality and dependence for activities of daily living (ADL) were recorded at 1 week (D7) and 3 months (D90).
Among the 151 patients (mean age 85.4 ± 5.8 years) enrolled, atypical presentation prevalence was 21.2%. D7 and D90 mortality rates were 7.9% and 40.0%, respectively. Atypical presentation was independently associated with D7 (odds ratio (OR) 4.46, 95% confidence interval (CI) 1.04-19.24) and D90 mortality (OR 3.76, 95% CI 1.30-10.92) after controlling for other prognostic factors. Patients with diabetes and those infected with Staphylococcus aureus were more likely to have atypical signs of infection. ADL score decreased from 3.6 ± 2.0 before bacteremia to 2.8 ± 2.1 at D90 (P < 0.001).
Patients who are older with bacteremia have poor vital and functional prognoses in the short and long terms. The absence of typical signs of infection is associated with mortality. Blood culture should be considered for patients who are older, especially with diabetes with acute unexplained clinical manifestations.
High positivity of blood cultures obtained within two hours after shaking chills
2018, International Journal of Infectious Diseases
Citation Excerpt :
This was because it was believed that there was a time lag of around an hour between the abrupt influx of bacteria and the onset of chills (Bennett and Beeson, 1954). The most severe degree of chills, namely shaking chills or shivering, has been considered a strong predictor of bacteremia (Bates et al., 1990; Tokuda et al., 2005). Shaking chills have been a useful indicator of bacteremia even in elderly patients with dementia, because they are easily recognized (Taniguchi et al., 2013).
To determine whether the time lag between blood culture draw and the start of shaking chills is associated with blood culture positivity.
A prospective observational study was undertaken from January 2013 to March 2015 at a referral center in Okinawa, Japan. All enrolled patients were adults with an episode of shaking chills who were newly admitted to the division of infectious diseases. The study exposure was the time lag between blood culture draw and the most recent episode of shaking chills.
Among patients whose blood cultures were obtained within 2 h after shaking chills started, the blood culture positivity was 53.6% (52/97), whereas among patients whose blood cultures were obtained after more than 2 h, the positivity was 37.6% (44/117) (p = 0.019). The adjusted odds ratio of blood culture positivity for samples drawn within 2 h after shaking chills was 1.88 (95% confidence interval 1.01–3.51, p = 0.046). Escherichia coli were the most frequently detected bacteria (58/105).
The positivity of blood cultures obtained within 2 h after the start of the most recent shaking chills was higher than that for blood cultures obtained after 2 h.
Limited utility of blood cultures in the management of febrile outpatient kidney transplant recipients
2017, Journal of Microbiology, Immunology and Infection
Blood cultures for patients suspected of having bacteremia are standard practice, although several studies demonstrate that blood cultures have limited utility because of a low true-positive rate and infrequent resultant changes in antibiotic treatment. However, most reports exclude immunocompromised patients such as transplant recipients. We assessed the utility of blood cultures in transplant recipients hospitalized for community-acquired infections and evaluated clinical characteristics to predict bacteremia.
This retrospective study included 136 febrile cases in 97 kidney transplant recipients admitted to our hospital for whom blood cultures were performed between February 2001 and March 2013.
Among the 136 cases, blood cultures were positive, contaminated, and negative in seven (5.1%) cases, 12 (8.8%) cases, and 117 cases (86.1%), respectively. All bacteria detected in the seven cases were sensitive to the initial empirical antibiotics. Antibiotic treatment was changed based on the blood culture results only in one case for which the coverage was narrowed. The white blood cell count and C-reactive protein level were significantly higher in the patients with bacteremia. The predictive model based on these two factors successfully identified the high-risk group with a sensitivity and specificity of 86% and 91%, respectively.
Among the outpatient kidney transplant recipients, positive blood cultures were uncommon and scarcely affected antibiotic therapy, especially in patients with upper respiratory tract or urinary tract infections. Therefore, it may be reasonable to perform blood cultures only for patients with marked leukocytosis and high C-reactive protein level, even among transplant recipients.
Development and validation of a parsimonious and pragmatic CHARM score to predict mortality in patients with suspected sepsis
2017, American Journal of Emergency Medicine
Citation Excerpt :
In contrast to our results, the presence of chills has often been deemed a sign of active infection, or a ‘toxic’ sign. Chills has also been associated with higher circulating tumor necrosis factor-α and interleukin-10 levels [19,20] and the presence of bacteremia [21-23]. One explanation is that ED patients often remained in an early stage of sepsis, at which point not many patients developed chills as a presenting symptom.
We aimed to derive and validate a parsimonious and pragmatic clinical prediction rule using the concepts of Predisposition, Infection, Response, and Organ Dysfunction to predict in-hospital mortality; and to compare it with other prediction rules, as well as with conventional biomarkers for evaluating the mortality risk of patients with suspected sepsis in the emergency department (ED).
We conducted a pragmatic cohort study with consecutive ED patients aged 18 or older with documented diagnostic codes of infection and two sets of blood culture ordered by physicians between 2010 and 2012 in a tertiary teaching hospital.
7011 and 12,110 patients were included in the derivation cohort and the validation cohort for the final analysis. There were 479 deaths (7%) in the derivation cohort and 1145 deaths (9%) in the validation cohort. Independent predictors of death were absence of Chills (odds ratio: 2.28, 95% confidence interval: 1.75–2.97), Hypothermia (2.12, 1.57–2.85), Anemia (2.45, 1.97–3.04), wide Red cell Distribution Width (RDW) (3.27, 2.63–4.05) and history of Malignancy (2.00, 1.63–2.46). This novel clinical prediction rule (CHARM) performed well for stratifying patients into mortality risk groups (sensitivity: 99.4%, negative predictive value 99.7%, receiver operating characteristic area 0.77). The CHARM score also outperformed the other scores or biomarkers such as PIRO, SIRS, MEDS, CURB-65, C-reactive protein, procalcitonin and lactate (all p < .05).
In patients with suspected sepsis, this parsimonious and pragmatic model could be utilized to stratify the mortality risk of patients in the early stage of sepsis.
Best Clinical Practice: Blood Culture Utility in the Emergency Department
2016, Journal of Emergency Medicine
Bacteremia affects 200,000 patients per year, with the potential for significant morbidity and mortality. Blood cultures are considered the most sensitive method for detecting bacteremia and are commonly obtained in patients with fever, chills, leukocytosis, focal infections, and sepsis.
We sought to provide emergency physicians with a review of the literature concerning blood cultures in the emergency department.
The utility of blood cultures has been a focus of controversy, prompting research evaluating effects on patient management. Bacteremia is associated with increased mortality, and blood cultures are often obtained for suspected infection. False-positive blood cultures are associated with harm, including increased duration of stay and cost. This review suggests that blood cultures are not recommended for patients with cellulitis, simple pyelonephritis, and community-acquired pneumonia, because the chance of a false-positive culture is greater than the prevalence of true positive cultures. Blood cultures are recommended for patients with sepsis, meningitis, complicated pyelonephritis, endocarditis, and health care–associated pneumonia. Clinical prediction rules that predict true positive cultures may prove useful. The clinical picture should take precedence. If cultures are obtained, two bottles of ≥7 mL should be obtained from separate peripheral sites.
Blood cultures are commonly obtained but demonstrate low yield in cellulitis, simple pyelonephritis, and community-acquired pneumonia. The Shapiro decision rule for predicting true bacteremia does show promise, but clinical gestalt should take precedence. To maximize utility, blood cultures should be obtained before antibiotic therapy begins. At least two blood cultures should be obtained from separate peripheral sites.
Risk of bacteremia in patients presenting with shaking chills and vomiting - A prospective cohort study
2020, Epidemiology and Infection

View all citing articles on Scopus

View full text

Clinical research studyThe degree of chills for risk of bacteremia in acute febrile illness

Abstract

Purpose

Methods

Results

Conclusion

Section snippets

Patient assembly and data collection

Statistical analysis

Results

Discussion

Acknowledgment

Blood culturesissues and controversies

Rev Infect Dis.

Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine

Chest

Clinical issues of blood cultures

Arch Intern Med.

Blood cultures

Ann Intern Med.

Bacteremia in febrile patients. A clinical model for diagnosis

Arch Intern Med.

Difficulty in predicting bacteremia in elderly emergency patients

Ann Emerg Med.

Inconsistency of a model aimed at predicting bacteremia in hospitalized patients

J Clin Epidemiol.

Predicting bacteremia in hospitalized patients. A prospectively validated model

Ann Intern Med.

Predictors of bacteremia and gram-negative bacteremia in patients with sepsis

Arch Intern Med.

Predicting bacteremia in patients with sepsis syndrome

J Infect Dis.

Validation of a bacteremia prediction model

Infect Control Hosp Epidemiol.

Low serum procalcitonin level accurately predicts the absence of bacteremia in adult patients with acute fever

Clin Infect Dis.

Laboratory markers of systemic inflammation as predictors of bloodstream infection in acutely ill patients admitted to hospital in medical emergency

Eur J Clin Microbiol Infect Dis.

Markers of bacteremia in febrile neutropenic patients with hematological malignanciesprocalcitonin and IL-6 are more reliable than C-reactive protein

Eur J Clin Microbiol Infect Dis.

Fever, shock and chills in gram-negative bacillemiaclinical correlations in 100 cases

Johns Hopkins Med J.

Implications of chills

Lancet.

Clinical research study
The degree of chills for risk of bacteremia in acute febrile illness