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Original Research

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Predictive factors for identifying infection source using combined chest-abdominal computed tomography in acute febrile older patients exhibiting no clinical indications in the emergency department

  • Won Young Sung1
  • Jin Cheol Kim1
  • Sang Won Seo1
  • Keun Taek Lee1
  • Heebum Yang2,*,

1Department of Emergency Medicine, Daejeon Eulji Medical Center, Eulji University, 35233 Daejeon, Republic of Korea

2Department of Emergency Medicine, Uijeongbu Eulji Medical Center, Eulji University, 11759 Uijeongbu-si, Republic of Korea

DOI: 10.22514/sv.2024.086 Vol.20,Issue 7,July 2024 pp.86-95

Submitted: 28 November 2023 Accepted: 04 January 2024

Published: 08 July 2024

*Corresponding Author(s): Heebum Yang E-mail:


Diagnosing fever in older patients is challenging because of atypical symptom presentation. Understanding which factors can predict an infection source on systemic computed tomography (CT) scans can improve patient outcomes by informing treatment decisions. This study aimed to investigate the predictive factors for identifying infection source using combined chest and abdominal CT in older febrile patients exhibiting no clear indications in the emergency department (ED). This was a single-center retrospective study that enrolled 169 acute febrile older patients without any clinical evidence of fever, who underwent systemic CT in the ED between January 2017 and June 2019. Fever in older patients was defined as tympanic temperature ≥37.2 ℃or an increase in body temperature by ≥1.3 ℃. Lack of clinical evidence of fever included an absence of suggestive findings in medical history, review of systems, physical examination or basic emergency diagnostic tests. CT results revealed 98 and 71 patients with negative and positive infection sources, respectively. Multivariate logistic regression analysis identified underlying diabetes mellitus (odds ratio (OR) = 2.667, 95% confidence interval (CI): 1.209–5.883, p = 0.015) and malignancy (OR = 13.272, 95% CI: 2.590–67.990, p = 0.002), quick Sequential Organ Failure Assessment score of 2 or more (≥2 points) (OR = 6.687, 95% CI: 2.568–17.410, p < 0.001), and serum C-reactive protein greater than 5.15 mg/dL (>5.15 mg/dL) (OR = 9.773, 95% CI: 3.944–24.217, p < 0.001) as independent predictive factors for infection source in acute febrile older patients showing no clinical evidence in the ED. Physicians could consider recommending systemic CT scans when there is a high clinical benefit for acute febrile older patients who lack clear evidence of fever but have the predictive factors identified in this study.


Aged; Emergency department; Fever; Infections; Tomography

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Won Young Sung,Jin Cheol Kim,Sang Won Seo,Keun Taek Lee,Heebum Yang. Predictive factors for identifying infection source using combined chest-abdominal computed tomography in acute febrile older patients exhibiting no clinical indications in the emergency department. Signa Vitae. 2024. 20(7);86-95.


[1] Organisation for Economic Co-operation and Development. Elderly population (indicator). 2023. Available at: (Accessed: 28 December 2023).

[2] Norman DC. Fever in the elderly. Clinical Infectious Diseases. 2000; 31: 148–151.

[3] Schoevaerdts D, Sibille F, Gavazzi G. Infections in the older population: what do we know? Aging Clinical and Experimental Research. 2021; 33: 689–701.

[4] Scott MM, Liang SY. Infections in older adults. Emergency Medicine Clinics of North America. 2021; 39: 379–394.

[5] Just KS, Defosse JM, Grensemann J, Wappler F, Sakka SG. Computed tomography for the identification of a potential infectious source in critically ill surgical patients. Journal of Critical Care. 2015; 30: 386–389.

[6] Di Serafino M, Viscardi D, Iacobellis F, Giugliano L, Barbuto L, Oliva G, et al. Computed tomography imaging of septic shock. Beyond the cause: the “CT hypoperfusion complex”. A pictorial essay. Insights into Imaging. 2021; 12: 70.

[7] Seo H, Cha S, Shin K, Lim J, Yoo S, Lee S, et al. Community-acquired pneumonia with negative chest radiography findings: clinical and radiological features. Respiration. 2019; 97: 508–517.

[8] Nebelung H, Wotschel N, Held HC, Kirchberg J, Weitz J, Radosa CG, et al. ICU patients with infectious complications after abdominopelvic surgery: is thoracic CT in addition to abdominal CT helpful? Annals of Intensive Care. 2023; 13: 6.

[9] Boland GWL, Guimaraes AS, Mueller PR. The radiologist’s conundrum: benefits and costs of increasing CT capacity and utilization. European Radiology. 2009; 19: 9–11.

[10] Berlyand Y, Fraga JA, Succi MD, Yun BJ, Lee AH, Baugh JJ, et al. Impact of iodinated contrast allergies on emergency department operations. The American Journal of Emergency Medicine. 2022; 61: 127–130.

[11] Rehani MM, Yang K, Melick ER, Heil J, Šalát D, Sensakovic WF, et al. Patients undergoing recurrent CT scans: assessing the magnitude. European Radiology. 2020; 30: 1828–1836.

[12] Lee CH, Sung WY, Lee JY, Lee WS, Seo SW. Usefulness of combined chest and abdominal computed tomography for identification of infection sources in febrile patients without clinical clue. The Korean Society of Emergency Medicine. 2019; 30: 147–154. (In Korean)

[13] Sert ET, Kokulu K. Role of thoracic and abdominal tomography in identifying a potential source of infection in patients with acute fever of unknown focus. The American Journal of Emergency Medicine. 2021; 50: 256–259.

[14] Güneş UY, Zaybak A. Does the body temperature change in older people? Journal of Clinical Nursing. 2008; 17: 2284–2287.

[15] Hernandes Júnior PR, Sardeli AV. The effect of aging on body temperature: a systematic review and meta-analysis. Current Aging Science. 2021; 14: 191–200.

[16] Chung MH, Huang CC, Vong SC, Yang TM, Chen KT, Lin HJ, et al. Geriatric fever score: a new decision rule for geriatric care. PLOS ONE. 2014; 9: e110927.

[17] Seymour CW, Liu VX, Iwashyna TJ, Brunkhorst FM, Rea TD, Scherag A, et al. Assessment of clinical criteria for sepsis: for the third international consensus definitions for sepsis and septic shock (sepsis-3). JAMA. 2016; 315: 762–764.

[18] Freund Y, Lemachatti N, Krastinova E, Van Laer M, Claessens Y, Avondo A, et al. Prognostic accuracy of sepsis-3 criteria for in-hospital mortality among patients with suspected infection presenting to the emergency department. JAMA. 2017; 317: 301–308.

[19] Hoel RW, Giddings Connolly RM, Takahashi PY. Polypharmacy management in older patients. Mayo Clinic Proceedings. 2021; 96: 242–256.

[20] Taylor SP, Shah M, Kowalkowski MA, Taylor B, Chou S. First-to-second antibiotic delay and hospital mortality among emergency department patients with suspected sepsis. The American Journal of Emergency Medicine. 2021; 46: 20–22.

[21] Müskens JLJM, Kool RB, van Dulmen SA, Westert GP. Overuse of diagnostic testing in healthcare: a systematic review. BMJ Quality & Safety. 2022; 31: 54–63.

[22] Bleeker-Rovers CP, Vos FJ, de Kleijn EMHA, Mudde AH, Dofferhoff TSM, Richter C, et al. A prospective multicenter study on fever of unknown origin: the yield of a structured diagnostic protocol. Medicine. 2007; 86: 26–38.

[23] Rajagopalan S. Serious infections in elderly patients with diabetes mellitus. Clinical Infectious Diseases. 2005; 40: 990–996.

[24] Zhou K, Lansang MC. Diabetes mellitus and infections. 2021. Available at: (Accessed: 29 December 2023).

[25] Hyernard C, Breining A, Duc S, Kobeh D, Dubos M, Prevel R, et al. Atypical presentation of bacteremia in older patients is a risk factor for death. The American Journal of Medicine. 2019; 132: 1344–1352.e1.

[26] Hagen KM, Ousman SS. Aging and the immune response in diabetic peripheral neuropathy. Journal of Neuroimmunology. 2021; 355: 577574.

[27] Cisneros B, García-Aguirre I, Unzueta J, Arrieta-Cruz I, González-Morales O, Domínguez-Larrieta JM, et al. Immune system modulation in aging: molecular mechanisms and therapeutic targets. Frontiers in Immunology. 2022; 13: 1059173.

[28] Berben L, Floris G, Wildiers H, Hatse S. Cancer and aging: two tightly interconnected biological processes. Cancers. 2021; 13: 1400.

[29] Rolston KVI. Infections in cancer patients with solid tumors: a review. Infectious Diseases and Therapy. 2017; 6: 69–83.

[30] Loddo S, Salis F, Rundeddu S, Serchisu L, Peralta MM, Mandas A. Nutritional status and potentially inappropriate medications in elderly. Journal of Clinical Medicine. 2022; 11: 3465.

[31] Zincircioğlu Ç, Rollas K, Güldoğan IK, Sarıtaş A, Özkarakaş H, Ersan G, et al. Diagnostic value of procalcitonin and C reactive protein for infection and sepsis in elderly patients. Turkish Journal of Medical Sciences. 2021; 51: 2649–2656.

[32] Lin W, Huang H, Wen J, Chen G, Lin X, Shi S. The predictive value of procalcitonin for early detection of infection in elderly type 2 diabetes mellitus. Journal of Infection and Chemotherapy. 2020; 26: 343–348.

[33] Tatar D, Senol G, Anar C, Tibet G. Markers of lower respiratory tract infections in emergency departments. Multidisciplinary Respiratory Medicine. 2013; 8: 20.

[34] Coyle JP, Brennan CR, Parfrey SF, O’Connor OJ, Mc Laughlin PD, Mc Williams SR, et al. Is serum C-reactive protein a reliable predictor of abdomino-pelvic CT findings in the clinical setting of the non-traumatic acute abdomen? Emergency Radiology. 2012; 19: 455–462.

[35] Beydoğan E, Yürük Atasoy P. The relationship between CRP at admission and thorax CT findings in patients diagnosed with COVID-19. International Journal of Clinical Practice. 2021; 75: e14962.

[36] Escadafal C, Incardona S, Fernandez-Carballo BL, Dittrich S. The good and the bad: using C reactive protein to distinguish bacterial from non-bacterial infection among febrile patients in low-resource settings. BMJ Global Health. 2020; 5: e002396.

[37] Ward A Maia I, Oliveira J E Silva L, Herpich H, Diogo L, Batista Santana JC, Pedrollo D, et al. Prognostic accuracy of qSOFA at triage in patients with suspected infection in a Brazilian emergency department. The American Journal of Emergency Medicine. 2021; 50: 41–45.

[38] Hamabe F, Terayama T, Mikoshi A, Murakami W, Yamada K, Soga S, et al. Usefulness of computed tomography for hospitalized adult patients with fever to investigate cause of fever: single-center, retrospective cohort study. Japanese Journal of Radiology. 2021; 39: 802–810.

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