236 Table 1. Comparison of Febrile, Vaccinated Surgical Patients by Surgical Status Surgery Servicea Variable
No. of patients who received influenza vaccination ∙ Prior to the surgical procedure, no. (%) ∙ After the surgical procedure, no. (%) Fever within 48 h of vaccination, no. (%) Maximum temperature (°C), median (IQR)
Time of vaccination to fever postvaccination, median (IQR) Infectious investigations, no. (%)b ∙ Positive for infection, no. ∙ Negative for infection, no. Length of stay, median (IQR)
Elective Surgery (n=13)
3 (23.1) 10 (76.9) 12 (92.3)
38.5 (38.4–38.7) 11.1 (6.3–25.6) 6 (46.1) 0 6
5.0 (3.0–7.5)
Nonelective Surgery (n=16)
8 (50) 8 (50)
7 (43.6)
38.4 (38.3–38.7) 19.1 (4.6–24.9) 3 (18.6) 0 3
14.5 (6.0–29.3)
a6 surgical patients did not undergo any procedure. bInfectious investigation was defined as obtaining one or more of the following within 48 hours of fever onset: blood cultures, urinalysis, urine cultures and/or chest X-ray.
IQR) for continuous variables. We used χ2 andMann-Whitney U tests for comparisons where appropriate. All tests were 2-tailed, and a P value of<.05 was considered statistically significant. The Washington University Human Research Protection Office approved this study.
Results
Of 32,998 admissions, 96% were screened for influenza vaccination status and 4,185 patients (12.7%) were vaccinated. Medical patients received vaccination earlier in their hospital admission than surgical patients: 13.0 hours (IQR, 5.2–27.8) versus 25.9 hours (IQR, 15.0– 165.2) (P=.001). Moreover, sixty-three vaccinated inpatients (1.5%) experienced PIV fever. Among them, 28 (44.4%) and 35 (55.6%) patients were admitted to medical and surgical services, respectively. The median maximum temperature was significantly higher among medical vs. surgical patients: 38.7°C (IQR, 38.4–39.3) versus 38.4°C (IQR, 38.3–38.7) (P=.04). The mean time to fever after vaccination was not different between themedical and surgical patients: 10.9 hours (IQR, 5.4–27.3) versus 19.0 hours (IQR, 9.2–25.3) (P=.38). There was no difference between the median length of stay between febrile and nonfebrile patients postvaccination: 7 days versus 8 days (P=.58). In the subgroup analysis of febrile surgical patients, 13 (37.1%) and
16 (45.7%) patients underwent elective and nonelective procedures <48 hours after vaccination, respectively (Table 1). The remaining 6 patients (17.1%) did not have surgery. Compared with the nonelective procedure subgroup, patients who had elective surgery were more likely to develop perioperative fever within 48 hours PIV (P=.01). Never- theless, there was no significant difference in the proportion of patients who underwent an infectious investigation between the 2 subgroups (P=.11). None of the investigations were positive for an infectious etiology (Table 1). The nonelective subgroup tended to have a higher length of hospital stay than the elective surgical patients (P=.02). In total, 21 (75%) medical patients had fever attributable to con-
comitant infections (Table 2).Most of the surgical patients (76.9%) who underwent elective procedure had fever potentially explained by benign postoperative fever, while 10 (62.5%) cases in the nonelective surgical subgroup had fever more likely caused by concomitant infection. Overall, medical patients had fever predominantly caused by infections,
Infections Pulmonary
Cardiovascular Gastrointestinal Genitourinary
Skin and soft tissue infection
Bone and joint
Bloodstream infection
Febrile neutropenia
Noninfectious causes
Postsurgical fever Central fever
Postvaccination fever
0 1
10 2
3 3
10 0 Othersb 50 0
aSome patients could have 2 or more infectious processes. bOthers include acute pancreatitis or myocardial infection.
while surgical patients had febrile illness explained by noninfectious etiologies (P=.03). None of the patients with noninfectious fever PIV were started on antibiotics within 48 hours of their fever.
0 0 0
0
Table 2. Causes of Fever Following Influenza Vaccination in the Hospitalized Medicine and Surgical Patients
Surgical Service (n=35)
Medical Servicea (n=28)
Elective Surgery (n=13)
4 0 3 5
0 0 0 0
Nonelective Surgery (n=16)
1 1 4 2
21 2 3 0 0 60 0 20 0
No Surgical Intervention (n=6)
2 1 1 0 1
0 1
0 P Value .14
.01 .53 .78 .11
Kap Sum Foong et al
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