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Approach of Infected patient in Critical Care Unit

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Approach of Infected patient in Critical Care Unit Mazen Kherallah, MD, FCCP Consultant, Infectious Disease & Critical Care Chairman, Critical Care Department – PowerPoint PPT presentation

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Title: Approach of Infected patient in Critical Care Unit


1
Approach of Infected patient in Critical Care Unit
  • Mazen Kherallah, MD, FCCP
  • Consultant, Infectious Disease Critical Care
    Chairman, Critical Care Department
  • King Faisal Specialist Hospital Research Center

2
1. What Sepsis Syndrome are we Dealing with?
  • Infection
  • Sepsis
  • Severe sepsis
  • Septic shock
  • Multi-organ system failure

3
ACCP/SCCM Consensus Definitions
  • Infection
  • Inflammatory response to microorganisms, or
  • Invasion of normally sterile tissues
  • Systemic Inflammatory Response Syndrome (SIRS)
  • Systemic response to a variety of processes
  • Sepsis
  • Infection plus
  • ?2 SIRS criteria
  • Severe Sepsis
  • Sepsis
  • Organ dysfunction
  • Septic shock
  • Sepsis
  • Hypotension despite fluid resuscitation
  • Multiple Organ Dysfunction Syndrome (MODS)
  • Altered organ function in an acutely ill patient
  • Homeostasis cannot be maintained without
    intervention

Bone RC et al. Chest. 19921011644-55.
4
SIRS More Than Just a Systemic Inflammatory
Response
  • SIRS A clinical response arising from a
    nonspecific insult manifested by ?2 of the
    following
  • Temperature ?38C or ?36C
  • HR ?90 beats/min
  • Respirations ?20/min
  • WBC count ?12,000/mL or ?4,000/mL or gt10
    immature neutrophils
  • Recent evidence indicates that hemostatic changes
    are also involved

Adapted from Bone RC et al. Chest.
19921011644-55. Opal SM et al. Crit Care Med.
200028S81-2.
5
Severe Sepsis Acute Organ Dysfunction and
Disordered Hemostasis
  • Severe Sepsis Sepsis with signs of organ
    dysfunction in ?1 of the following systems
  • Cardiovascular
  • Renal
  • Respiratory
  • Hepatic
  • Hemostasis
  • CNS
  • Unexplained metabolic acidosis

Adapted from Bone RC et al. Chest.
19921011644-55.
6
Sepsis Syndromes
Infection Sepsis Severe
Sepsis Septic Shock
Microbiological Phenomenon
Infection SIRS
Sepsis End-Organ Damage
Severe Sepsis Refractory Hypotension
7
Sepsis Parameters
  • Leukocytosis with left shift
  • Bandemia
  • Toxic granulation
  • Elevated sed. Rate
  • C- reactive protein
  • Acute phase reactant fibrinogen, haptoglobin,..
  • IL1, IL6, IL8

8
2. Organ Localization of infection
  • Skin
  • Soft tissue
  • CNS
  • Upper airway
  • Lower airway
  • Head and neck
  • Mediastinal
  • GI
  • Liver
  • Biliary tract
  • Intra-abdominal
  • Bones and joints
  • Urinary tract
  • Genital tract
  • Blood stream infection
  • Systemic

9
3. Tissue Localization of Infection
  • Skin and soft tissue
  • Superficial epidermal layers (impetigo)
  • Deeper epidermal layers (Icthyma)
  • Superficial subcutaneous Erysipelas
  • Deeper subcut. cellulitis
  • Folliculitis
  • Hydradenitis
  • Fascia Fasciitis
  • Fat panuculitis
  • Lower respiratory tract
  • Alveolar consolidative pneumonia
  • Interstitial atypical pneumonia
  • Pleural empyema

10
4. Suspected Microbiology of Infection
  • Host factors
  • Immunosuppression
  • Age
  • Gender
  • Previous antibiotics
  • Co-morbidity
  • SSD
  • DM
  • CGD
  • Environmental
  • Community
  • contacts
  • Travel
  • Animals
  • Hospital
  • Location
  • Nursing homes

11
4. Suspected Microbiology of Infection
  • Community acquired pneumonia Lobar pneumonia
  • Streptococcus Pn.
  • H. flu
  • Moraxella catarrhalis
  • Staphylococcal
  • Klebsiella
  • Community acquired pneumonia interstitial
  • Mycoplasma Pn.
  • Legionella
  • Viral

12
4. Suspected Microbiology of Infection
  • Intra-abdominal infection
  • E. coli
  • Klebsiella
  • B. fragilis
  • Enterococcus
  • Candida
  • Urinary tract infection
  • E. coli
  • Proteus
  • Enterococcus

13
4. Suspected Microbiology of Infection
  • Meningitis lt1 month
  • Group B strep 49
  • E. Coli 18
  • Listeria 7
  • Gram neg. 10
  • Meningitis 1 mo-50 yrs
  • S. pneumoniae
  • Meningococci
  • H. flu (very rare)

14
5. Surgical Indication
  • Foreign body central line infection
  • Prosthesis PVE, Prosthetic infection
  • Sequestration chronic osteomyelitis
  • Gangrene wet gangrene
  • Obstructed normal draining procedure
    cholecystitis
  • No penetration for antibiotics empyema, abscess

15
5. Empiric Treatment
  • Appropriate coverage
  • Adequate dose MIC, MBC
  • Appropriate route
  • Absorption
  • Penetration
  • Tissue level
  • Cellular level

16
4. Suspected Microbiology of Infection
  • Meningitis lt1 month
  • Group B strep 49
  • E. Coli 18
  • Listeria 7
  • Gram neg. 10
  • AmpicillinCefotaxime
  • Meningitis 1 mo-50 yrs
  • S. pneumoniae
  • Meningococci
  • H. flu (very rare)
  • VancomycinCeftriaxone or cefotaxime

17
Empiric Treatment Intra-abdominal Infection
  • E. coli, Klebsiella
  • Amp/sulbactam
  • Piperacillin/tazobactam
  • Ticarcillin/clavaulinate
  • Aztreonam
  • Imipenem
  • Cefazolin
  • Cefuroxime
  • Ceftriaxone
  • Ciprofloxacin
  • B. Fragilis
  • Amp/sulbactam
  • Piperacillin/tazobactam
  • Ticarcillin/clavaulinate
  • Imipenem
  • Cefoxitin
  • Clindamycin
  • Metronidazole
  • Chloramphonicole

18
IntroductionFever Work-Up
  • Automatic set order
  • Repeated several times within 24 hours
  • Time consuming
  • Costly
  • Disruptive and patients discomfort
  • Considerable blood loss
  • Unneeded radiation

19
Practice ParametersGoals
  • Rational consumption of resources
  • Efficient evaluation

20
The Search for the Underlying Cause of Fever?
  • What temperature should elicit an evaluation?
  • When are blood cultures warranted
  • When should intravascular catheters be cultured
    or removed
  • When are cultures of respiratory secretions,
    urine, stool, or CSF warranted
  • When are radiological studies warranted

21
Initiating Fever EvaluationDefinition of Fever
  • Arbitrary core temperature gt38.0C, or two
    consecutive elevation of gt 38.3C
  • The lower the temperature that is used to define
    fever, the more sensitive and less specific the
    indicator is for detecting an infectious etiology

22
Initiating Fever Evaluation Normal Body
Temperature
  • Normal body temperature is 37.0C
  • Varies by 0.5C to 1C according to circadian
    rhythm and menstrual cycle
  • Exercise can increase temperature by 2C to 3C

23
Initiating Fever Evaluation Variation of
Temperature in ICU
  • Specialized mattresses
  • Hot lights
  • Air conditioning
  • Cardiopulmonary bypass
  • Peritoneal lavage
  • Dialysis and continuous hemofiltration
  • Drugs altering thermoregulatory mechanisms

24
Initiating Fever Evaluation Non-infectious
Causes of Fever can be Life-threatening
  • Adrenal insufficiency
  • Thyroid storm
  • Malignant hyperthermia
  • Heat stroke

25
Initiating Fever Evaluation Infected Patient but
Afebrile
  • Elderly
  • Open abdominal wounds
  • Large burns
  • Extracorporeal membrane oxygenation
  • Patients taking anti-inflammatory or anti-pyretic
    drugs

26
Initiating Fever Evaluation Temperature
Measurement
  • Most accurately measured using intravascular or
    bladder thermistor
  • Mouth, rectal or external auditory measurements
    using electronic probes is acceptable in
    appropriate patients
  • Axillary measurements should not be used

27
Initiating Fever Evaluation Clinical Evaluation
  • A new onset of temperature to or above 38.3C is
    reasonable trigger for a clinical assessment but
    not necessarily a laboratory or radiological
    evaluation
  • Clinical assessment may reveal a purulent wound
    or phlebitic leg, then diagnosis and therapy for
    that infectious process should commence

28
Bacterial Synergistic Gangrene
29
Anaerobic Cellulitis
30
Initiating Fever Evaluation Obtaining Blood
CulturesSkin Preperation
  • The site of venipunture should be cleaned with
    either 10 povidone iodine or 1-2 tincture of
    iodine. If the patient is allergic to iodine
    alcohol 70 swabs should be used
  • The access to intravascular device and to the
    stopper on the culture bottle should be cleaned
    with 70 alcohol
  • Iodophors must be allowed to dry to provide
    maximal antiseptic activity

31
Initiating Fever Evaluation Obtaining Blood
CulturesBlood Volume
  • One blood culture is defined as a sample of blood
    drawn at a single time at a single site
  • One milliliter of blood is needed per five
    milliliter of media
  • 5 ml of blood is injected into each of two or
    three bottles for routine blood culture
  • 10-15 ml per one set of blood cultre

32
Initiating Fever Evaluation Obtaining Blood
CulturesNumber of Cultures Sites
  • Two cultures 10 minutes apart after the onset of
    fever. Culture should not be repeated till 24
    hours passed
  • Each culture should be drawn by separate
    venipuncture
  • One culture can be obtained from the most
    recently inserted catheter in case venipuncture
    is difficult (the second B/C from a venipuncture
    site)

33
Initiating Fever EvaluationCXR Sputum
  • Chest x-ray in an erect sitting position during
    deep inspiration
  • The absence of infiltrates, masses or effusion
    does not exclude pneumonia, abscess or empyema
  • Respiratory secretion obtained by suctioned or
    expectorated sputum is adequate for initial
    evaluation

34
Initiating Fever EvaluationUrinalysis and Urine
Culture
  • Obtain urine for culture and for determination of
    the presence of pyuria
  • Patients who have Foley catheter in place should
    have urine collected from the urine port of the
    catheter and not from the drainage bag
  • Urine should be transported to the laboratory
    rapidly to avoid bacterial multiplication,
    otherwise should be refrigerated

35
Initiating Fever EvaluationStool Examination
  • Mandatory when more than 2 stools per day conform
    to the container in which they are placed in a
    patient at risk for C-difficile
  • Stool should be sent for WBC or lactoferrin latex
    agglutination test
  • Stool should be sent for c-diff assay for at
    least 2 times in 24 hours
  • Stool should not be sent for other enteric
    pathogens unless the patient is HIV or present to
    the hospital with diarrhea

36
Infectious Causes of Fever
  • Catheter-related Infections
  • ICU acquired Pneumonia
  • Urinary Tract Infection
  • Pseudomembraneous colitis
  • Wound Infection
  • Sinusitis
  • Acaculous cholecystitis

37
Vascular Devices fever
  • Localized infection
  • Exit site infection
  • Tunnel infection
  • Systemic infection
  • Allergic reaction

38
Relative Risks of CR-BSI
  • Duration of catheter in place
  • Anatomic site of insertion
  • Type of the device
  • Catheter composition
  • A-Line, Central line, Hickmans catheter
  • Regular vs antibiotic-impregnated catheter
  • Patient population
  • Techniques used in insertion and maintenance
  • Frequency of manipulation

39
Duration of Catheter UseOptimal Time for
Catheter Removal?
  • The incidence of CR-BSI is directly proportional
    to the length of time the catheter is used
  • The risk that any catheter may cause CR-BSI is
    low if the catheter is removed within 3 days
  • The optimal time for catheter removal is unknown

40
Anatomic Site of InsertionIncidence of Catheter
Colonization Kemp and associates
  • Femoral line 36
  • Internal jugular 17
  • Subclavian 5

41
Type of the DeviceRisk of CR-BSI
  • Short-term noncuffed central venous catheters
    5-10 cases per 1000 catheter days
  • Peripheral IV catheter less than 0.2 cases per
    1000 catheter days
  • Permanent surgically implanted central device 2
    bacteremias per 1000 catheter days

42
Catheter Related InfectionsDefinitionsColonized
Catheter
  • Positive culture from the catheter tip or
    intracutaneous segment without evidence of
    systemic infection
  • Semiquantitative culture of 15 or more CFU is
    used to consider culture as positive
  • Values of less than 15 CFU are regarded as
    negative culture, contaminant, or insignificant
    infection requiring no therapy

43
Catheter Related InfectionsDefinitionsCatheter-R
elated Bloodstream Infection
  • A positive catheter culture ?15 CFU with
    concomitant positive blood culture
  • A quantitative blood culture drawn from the
    catheter shows marked step-up in concentration of
    organisms (ten-fold or greater) as compared with
    peripherally drawn quantitative blood culture
  • No other identifiable source of infection

44
Catheter Related InfectionsDefinitionsInfusate-R
elated Bloodstream Infection
  • Isolation of the same organism from the infusate
    and from separate percutaneous peripheral blood
    culture
  • No other identifiable source of infection

45
Catheter Related InfectionsDefinitionsLocal
Catheter-Related Infection
  • Growth of 15 or more CFU from a catheter specimen
    by semiquantitative culture
  • Local signs of inflammation erythema, swelling,
    tenderness, purulent material
  • Negative peripheral blood culture

46
When the Catheter Should be Removed in a Febrile
Patient?No other identifiable Source
  • For stable patients with fever, there is no
    necessity to remove or change all indwelling
    catheters unless CR-BSI or Local infection is
    documented
  • If patients are in shock, manifest peripheral
    embolization, DIC or ARDS, removal of all
    intravascular catheters and reinsertion at new
    sites is indicated.

47
Pulmonary Infections FeverDiagnostic Strategies
  • Empirical strategy based only on clinical
    evaluation
  • Invasive strategy based on fiberoptic
    bronchoscopy and quantitative cultures of distal
    uncontaminated pulmonary secretions
  • Intermediate strategy based on quantitative
    culture of nonbronchoscopic sample

48
Diagnostic Strategy based on Clinical Evaluation
only
  • Fever, cough, sputum production, new pulmonary
    infiltrate and elevated leukocyte count.
  • May not be present in the hospitalized patients
    with nosocomial pneumonia
  • May be present but may not be caused by
    pneumonia CHF, ARDS, atelectasis

49
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50
Diagnostic Strategy based on Clinical Evaluation
only
Andrews et al, chest 198180254-258
51
Diagnostic Strategy based on Clinical Evaluation
only
Autopsy Results
Andrews et al, chest 198180254-258
52
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54
Chastre et al. Evaluation of bronchoscopic
techniques for the diagnosis of nosocomial
pneumonia. Am J Respir Crit Care Med 1995
152231-240
55
Diagnostic Strategy based on Invasive Evaluation
Bronchoalveolar Lavage

56
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58
Chastre et al. Evaluation of bronchoscopic
techniques for the diagnosis of nosocomial
pneumonia. Am J Respir Crit Care Med 1995
152231-240
59
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60
Diagnostic Strategy based on Invasive
EvaluationProtected Brush Specimen
61
Diagnostic Strategy based on Invasive Evaluation
Protected Brush SpecimenDrawbacks False
Negative Results
  • Bronchoscopy performed at an early stage of
    infection with bacterial burden below the
    concentration necessary to reach diagnostic
    significance
  • Specimens obtained from unaffected segments
  • Specimens incorrectly processed
  • Specimens obtained after initiation of a new
    antimicrobial therapy

62
Intermediate Strategy Based on Quantitative
Culture of Nonbronchoscopic Samples
Quantitative Cultures of Nonbronchoscopic Distal
Protected Specimen
  • Represents a good alternative in patients with
    very unstable conditions and in patients for whom
    it is not possible to delay the initiation of
    antimicrobial treatment while awaiting
    bronchoscopy
  • Diagnosis can be missed, especially in the case
    of upper lobes or left lung infection

63
Jourdain et al. Role of quantitative cultures of
Endotracheal aspirates for the diagnosis of
nosocomial pneumonia. Am J Resp Crit Care Med
1995 152241-246
68 VS 84
64
Intermediate Strategy Based on Quantitative
Culture of Nonbronchoscopic Samples
Quantitative Cultures of Endotracheal aspirates
65
Diarrhea Fever in ICU
  • Diarrhea is caused by enteral feeding or drugs
  • The only common enteric cause of fever in the ICU
    is Clostridium difficile
  • C. difficile accounts for about 25 of all cases
    of antibiotic-related diarrhea

66
Pseudomembraneous Colitis
67
Methylene Blue Stain
68
Cytotoxin Effect on Baby Hamster kidney Cells
69
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72
UTI Fever in ICU
  • The presence of pyuria can help establish the
    importance of urinary bacteria
  • Leukocyte esterase dipstick test is easy and
    simple
  • Gram stain of a centrifuged urine sediment may
    provide clues to the type of microorganisms
    present

73
Other Causes of Fever in ICURespiratory
  • Tracheobronchitis
  • Empyema
  • Lung abscess
  • Sinusitis

74
Other Causes of Fever in ICUWound Soft Tissue
  • Wound infection
  • Decubitus ulcers
  • Cellulitis
  • Deep-seated abscess sub-diaphragmatic

75
Other Causes of Fever in ICUGastrointestinal
  • Ischemic colitis
  • Acalculous cholecystitis
  • Cholangitis
  • Transfusion-related hepatitis CMV, hepatitis C,
    and hepatitis B
  • Intraabdominal abscess
  • Diverticulitis

76
Other Causes of Fever in ICUProsthetic Devices
  • Cardiac valve/pacemaker
  • Joint replacement prosthesis
  • Peritoneal dialysis catheter
  • CNS intraventricular shunt

77
Non-Infectious Source of Fever in ICUDrugs
  • Antibiotics B-lactam agents
  • Anti-epileptic drugs phenytoin
  • Antiarrythmics quinidine and procainamide
  • Antihypertensive methyldopa

78
Non-Infectious Source of Fever in
ICUPost-operative
  • Up till 72 hours postoperative
  • Atelectasis
  • Post-pericardiotomy syndrome

79
Non-Infectious Source of Fever in ICUVascular
Conditions
  • Deep venous thrombophlebitis
  • Pulmonary embolism and infarction
  • Bowel ischemia
  • Hemorrhage into CNS, retroperitonium, joint,
    lung, and adrenals
  • Myocardial infarction and Dresslers syndrome

80
Non-Infectious Source of Fever in
ICUInflammatory Conditions
  • Reaction to blood products
  • Proliferative phase of ARDS
  • Infusion of interleukin-2, granulocyte macrophage
    colony stimulating factor, and granulocyte colony
    stimulating factor
  • Postpericardiotomy syndrome
  • Pancreatitis
  • Vasculitis

81
Non-Infectious Source of Fever in ICUMetabolic
Conditions
  • Heat stroke
  • Malignant hyperthermia
  • Neuroleptic malignant syndrome
  • Adrenal insufficiency
  • Alcohol withdrawal
  • Seizures
  • Hyperthyroidism

82
Non-Infectious Source of Fever in ICUNeoplasms
  • Lymphoma
  • Renal cell carcinoma
  • Hepatoma
  • Malignant metastatic to the liver
  • Colon carcinoma
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