Can catheter-related bloodstream infections present without fever, especially in elderly or immunocompromised patients?

Can Catheter-Related Bloodstream Infections Present Without Fever?

Yes, catheter-related bloodstream infections (CRBSI) can absolutely present without fever, particularly in debilitated, elderly, or patients with renal injury who may not mount a febrile response. 1

Key Clinical Principle

Absence of fever does not rule out CRBSI or any other infection. 1 This is a critical diagnostic pitfall that clinicians must recognize, as relying solely on fever as a screening criterion will miss a significant subset of serious infections.

High-Risk Populations for Afebrile CRBSI

The following patient populations are particularly prone to presenting with CRBSI without fever:

• Elderly patients - may lack the physiologic reserve to mount a febrile response 1
• Debilitated patients - chronic illness impairs inflammatory responses 1
• Patients with renal injury - altered thermoregulation and immune dysfunction 1
• Immunocompromised patients - including neutropenic patients who may have blunted fever responses 1
• Patients already receiving antimicrobial therapy - approximately 15% of bacteremic older persons had "afebrile" bacteremia, many of whom were already on antibiotics 1

Alternative Clinical Presentations to Monitor

When fever is absent, CRBSI may manifest through:

• Nonspecific symptoms: lethargy, confusion, falls, abdominal pain, nausea, vomiting, and incontinence 1
• Hemodynamic instability: hypotension (systolic BP <90 mmHg) or shock 1, 2
• Local catheter site findings: erythema, tenderness, induration, or purulent drainage within 2 cm of insertion site 2, 3
• Laboratory abnormalities: leukocytosis (>20,000 cells/mm³), bandemia (>1,500 cells/mm³), lymphopenia (<1,000 cells/mm³), or acute renal failure 1
• Respiratory compromise: respiratory failure or oliguria (<20 mL/hr) suggesting sepsis with organ dysfunction 1, 2

Diagnostic Approach for Suspected CRBSI Without Fever

Do not wait for fever to develop before investigating potential CRBSI in high-risk patients with catheters in place >48 hours. 2 Instead:

1. Obtain paired blood cultures immediately (one from catheter hub, one peripheral) if any systemic signs are present or the patient appears clinically unwell 1, 2

2. Inspect the catheter site daily by removing dressings to directly visualize for erythema, purulence, or induration 2

3. Consider differential time-to-positivity testing - a ≥2 hour earlier positivity from the catheter compared to peripheral blood suggests catheter source 2, 3

4. Culture catheter tip if removed - ≥15 CFU per segment (semiquantitative) or ≥10³ CFU (quantitative) confirms CRBSI 2

Organism-Specific Considerations

Coagulase-negative staphylococci (CNS) - the most common CRBSI pathogen - typically present with a milder or more indolent course that may lack prominent fever 1

Rapidly growing mycobacteria - can cause CRBSI in immunocompetent patients with minimal or absent fever, particularly in those with peripherally inserted central catheters (PICCs) 4, 5

Critical Clinical Caveat

Fever in a patient with a central vascular catheter does not necessarily mean CRBSI - numerous other infectious or non-infectious diagnoses may be the source. 1 Conversely, the absence of fever should never provide false reassurance when other clinical indicators suggest infection, particularly in vulnerable populations. 1

The mortality associated with bacteremia in elderly LTCF residents ranges from 18-50%, with 50% of deaths occurring within 24 hours of diagnosis, underscoring the importance of not delaying investigation due to absence of fever. 1