You opt to monitor the patient clinically and defer antibiotic initiation.
Over the next few days, a daily SAT and SBT are performed, but the patient hasn't been ready for extubation. His cardiac and pulmonary mechanics have seemed satisfactory, but he doesn't seem to be very bothered by being orotracheally intubated, suggesting he might not be able to protect his airway should the ETT be removed.
On ICU day 4, his temperature becomes elevated to 38C. It is 38.2C on re-check about two hours later. Current vitals are notable for BP 140/69, HR 96, Sp02 97%.
This patient has a true fever, with a temperature of ≥ 38C on subsequent checks. Fortunately, he seems hemodynamically stable. We do need to think about infection, and once that's ruled out, we could blame this on central fever. If there's an infection, most likely potential sources include pulmonary and urine. Workup can include blood cultures, tracheal aspirate or quantitative mini-BAL, and UA with reflex culture (fortunately he doesn't have a Foley catheter!).
In terms of whether to start antibiotics empirically, this patient is low risk at the moment. He's hemodynamically stable and not immunocompromised. We can wait for the workup and let the clinical situation dictate whether we start antibiotics.
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