Are corticosteroids or end-stage renal failure associated with afebrile presentation of Gram-negative bacteremia?

Abstract Assertions regarding afebrile presentation of sepsis frequently lead to superfluous antibiotic treatment. We aimed to identify risk factors for afebrile presentation of bacteremia, focusing on glucocorticoid (GC) treatment and end-stage renal disease (ESRD). In a retrospective cohort study, we included all patients with bacteremia caused by common Gram-negative bacteria in one hospital. The exposure variables were GC treatment, administered for at least 48 hours before bacteremia onset, and ESRD, defined as patients undergoing dialysis. We assessed risk factors for afebrile presentation, defined as temperature between 36.0° and 37.7°C for all measurements, 48 hours prior to blood culture collection. Analyses were subgrouped by community-onset and hospital-acquired Gram-negative bacteremia (GNB). Propensity-score-weighted multivariate analyses were conducted. Out of 4,179 patients with GNB, 1,090 (26.1%) presented without fever before blood culture collection. In community-onset GNB, GC treatment was significantly associated with afebrile presentation, PS-weighted OR 1.42 (95% CI, 1.25-1.61), absolute risk increase 7% (95% CI 4.3-9.8%) while ESRD was not. In hospital-acquired GNB, ESRD was significantly associated with afebrile presentation (OR 1.53; 95% CI 1.25-1.86; absolute risk increase 8.5%; 95% CI, 4.4-13.1%); GC was not. Other risk factors for afebrile presentation in both subgroups included increasing Charlson comorbidity score, bacteremia with non-fermenters P. aeruginosa or S. maltophila (compared to Enterobacteriaceae), and lower albumin levels. Aging was not associated with afebrile presentation of GNB. Though significant associations between GC and ESRD and afebrile presentation of GNB were observed, these were discrepant in community-onset and hospital-acquired GNBs, and absolute risk increases were small.