Approach of Infected patient Approach of Infected patient in Critical Care Unitin Critical Care Unit

Mazen Kherallah, MD, FCCPMazen Kherallah, MD, FCCP

Consultant, Infectious Disease & Critical Consultant, Infectious Disease & Critical Care Care Chairman, Critical Care Chairman, Critical Care

DepartmentDepartmentKing Faisal Specialist Hospital & Research King Faisal Specialist Hospital & Research

CenterCenter

1. What Sepsis Syndrome are we 1. What Sepsis Syndrome are we

Dealing with?Dealing with?

InfectionInfection SepsisSepsis Severe sepsisSevere sepsis Septic shockSeptic shock Multi-organ system failureMulti-organ system failure

ACCP/SCCM Consensus ACCP/SCCM Consensus DefinitionsDefinitions

InfectionInfection– Inflammatory response to Inflammatory response to

microorganisms, ormicroorganisms, or– Invasion of normally sterile Invasion of normally sterile

tissuestissues

Systemic Inflammatory Systemic Inflammatory Response Syndrome Response Syndrome (SIRS)(SIRS)– Systemic response to a Systemic response to a

variety of processesvariety of processes

SepsisSepsis– Infection plusInfection plus 2 SIRS criteria2 SIRS criteria

Severe SepsisSevere Sepsis– SepsisSepsis– Organ dysfunctionOrgan dysfunction

Septic shockSeptic shock– SepsisSepsis– Hypotension despite fluid Hypotension despite fluid

resuscitationresuscitation

Multiple Organ Multiple Organ Dysfunction Syndrome Dysfunction Syndrome (MODS)(MODS)– Altered organ function in an Altered organ function in an

acutely ill patientacutely ill patient– Homeostasis cannot be Homeostasis cannot be

maintained without maintained without interventionintervention

Bone RC et al. Chest. 1992;101:1644-55.

SIRS: More Than Just a Systemic SIRS: More Than Just a Systemic Inflammatory ResponseInflammatory Response

SIRS: A clinical response SIRS: A clinical response arising from a nonspecific arising from a nonspecific insult manifested by insult manifested by 2 of the following:2 of the following:– Temperature Temperature

38°C or 38°C or 36°C36°C– HR HR 90 beats/min90 beats/min– Respirations Respirations 20/min20/min– WBC count WBC count 12,000/12,000/L or L or

4,000/4,000/L or >10% L or >10% immature neutrophilsimmature neutrophils

Recent evidence Recent evidence indicates that hemostatic indicates that hemostatic changes are also changes are also involvedinvolved

Adapted from: Bone RC et al. Chest. 1992;101:1644-55.Opal SM et al. Crit Care Med. 2000;28:S81-2.

Severe Sepsis: Acute Organ Severe Sepsis: Acute Organ Dysfunction and Disordered Dysfunction and Disordered

HemostasisHemostasis

Severe Sepsis: Severe Sepsis: Sepsis with signs of Sepsis with signs of organ dysfunction in organ dysfunction in 1 of the following 1 of the following systems: systems: – CardiovascularCardiovascular– RenalRenal– RespiratoryRespiratory– HepaticHepatic– HemostasisHemostasis– CNSCNS– Unexplained metabolic Unexplained metabolic

acidosisacidosis

Adapted from: Bone RC et al. Chest. 1992;101:1644-55.

Sepsis SyndromesSepsis Syndromes

Infection Sepsis Severe Sepsis Septic Shock

MicrobiologicalPhenomenon

Infection +

SIRS

Sepsis +

End-Organ Damage

Severe Sepsis+

Refractory Hypotension

Sepsis Parameters:Sepsis Parameters:

Leukocytosis with left shiftLeukocytosis with left shift Bandemia Bandemia Toxic granulationToxic granulation Elevated sed. RateElevated sed. Rate C- reactive proteinC- reactive protein Acute phase reactant: fibrinogen, Acute phase reactant: fibrinogen,

haptoglobin,..haptoglobin,.. IL1, IL6, IL8IL1, IL6, IL8

2. Organ Localization of 2. Organ Localization of infection infection

SkinSkin Soft tissueSoft tissue CNSCNS Upper airwayUpper airway Lower airwayLower airway Head and neckHead and neck MediastinalMediastinal GI GI LiverLiver

Biliary tractBiliary tract Intra-abdominalIntra-abdominal Bones and jointsBones and joints Urinary tractUrinary tract Genital tractGenital tract Blood stream Blood stream

infectioninfection SystemicSystemic

3. Tissue Localization of 3. Tissue Localization of InfectionInfection

Skin and soft tissue:Skin and soft tissue:– Superficial epidermal layers Superficial epidermal layers

(impetigo)(impetigo)– Deeper epidermal layers Deeper epidermal layers

(Icthyma)(Icthyma)– Superficial subcutaneous: Superficial subcutaneous:

ErysipelasErysipelas– Deeper subcut.: cellulitisDeeper subcut.: cellulitis– FolliculitisFolliculitis– HydradenitisHydradenitis– Fascia: FasciitisFascia: Fasciitis– Fat: panuculitisFat: panuculitis

Lower respiratory Lower respiratory tract:tract:– Alveolar: Alveolar:

consolidative consolidative pneumoniapneumonia

– Interstitial: Interstitial: atypical atypical pneumoniapneumonia

– Pleural: empyemaPleural: empyema

4. Suspected Microbiology 4. Suspected Microbiology of Infectionof Infection

Host factorsHost factors– ImmunosuppressioImmunosuppressio

nn– AgeAge– GenderGender– Previous antibioticsPrevious antibiotics– Co-morbidity:Co-morbidity:

SSDSSD DMDM CGDCGD

EnvironmentalEnvironmental– Community:Community:

contactscontacts TravelTravel AnimalsAnimals

– Hospital:Hospital: LocationLocation

– Nursing homesNursing homes

4. Suspected Microbiology 4. Suspected Microbiology of Infectionof Infection

Community Community acquired acquired pneumonia: Lobar pneumonia: Lobar pneumoniapneumonia– Streptococcus Pn.Streptococcus Pn.– H. fluH. flu– Moraxella Moraxella

catarrhaliscatarrhalis– StaphylococcalStaphylococcal– KlebsiellaKlebsiella

Community Community acquired acquired pneumonia: pneumonia: interstitial:interstitial:– Mycoplasma Pn.Mycoplasma Pn.– LegionellaLegionella– ViralViral

4. Suspected Microbiology 4. Suspected Microbiology of Infectionof Infection

Intra-abdominal Intra-abdominal infectioninfection– E. coliE. coli– KlebsiellaKlebsiella– B. fragilisB. fragilis– EnterococcusEnterococcus– CandidaCandida

Urinary tract Urinary tract infectioninfection– E. coliE. coli– ProteusProteus– EnterococcusEnterococcus

4. Suspected Microbiology 4. Suspected Microbiology of Infectionof Infection

Meningitis: <1 Meningitis: <1 month:month:– Group B strep Group B strep

49%49%– E. Coli 18%E. Coli 18%– Listeria 7%Listeria 7%– Gram neg. 10%Gram neg. 10%

Meningitis: 1 mo-Meningitis: 1 mo-50 yrs:50 yrs:– S. pneumoniaeS. pneumoniae– MeningococciMeningococci– H. flu (very rare)H. flu (very rare)

5. Surgical Indication:5. Surgical Indication:

Foreign body: central line infectionForeign body: central line infection Prosthesis: PVE, Prosthetic infectionProsthesis: PVE, Prosthetic infection Sequestration: chronic osteomyelitisSequestration: chronic osteomyelitis Gangrene: wet gangreneGangrene: wet gangrene Obstructed normal draining procedure: Obstructed normal draining procedure:

cholecystitischolecystitis No penetration for antibiotics: No penetration for antibiotics:

empyema, abscessempyema, abscess

5. Empiric Treatment5. Empiric Treatment

Appropriate Appropriate coveragecoverage

Adequate dose: Adequate dose: MIC, MBC MIC, MBC

Appropriate routeAppropriate route

AbsorptionAbsorption PenetrationPenetration Tissue levelTissue level Cellular levelCellular level

4. Suspected Microbiology 4. Suspected Microbiology of Infectionof Infection

Meningitis: <1 Meningitis: <1 month:month:– Group B strep Group B strep

49%49%– E. Coli 18%E. Coli 18%– Listeria 7%Listeria 7%– Gram neg. 10%Gram neg. 10%

Ampicillin+CefotaAmpicillin+Cefotaximexime

Meningitis: 1 mo-Meningitis: 1 mo-50 yrs:50 yrs:– S. pneumoniaeS. pneumoniae– MeningococciMeningococci– H. flu (very rare)H. flu (very rare)

Vancomycin+CeftVancomycin+Ceftriaxone or riaxone or cefotaximecefotaxime

Empiric Treatment: Intra-Empiric Treatment: Intra-abdominal Infectionabdominal Infection

E. coli, KlebsiellaE. coli, Klebsiella– Amp/sulbactamAmp/sulbactam– Piperacillin/tazobactamPiperacillin/tazobactam– Ticarcillin/clavaulinateTicarcillin/clavaulinate– AztreonamAztreonam– ImipenemImipenem– CefazolinCefazolin– CefuroximeCefuroxime– CeftriaxoneCeftriaxone– CiprofloxacinCiprofloxacin

B. FragilisB. Fragilis– Amp/sulbactamAmp/sulbactam– Piperacillin/tazobactamPiperacillin/tazobactam– Ticarcillin/clavaulinateTicarcillin/clavaulinate– ImipenemImipenem– CefoxitinCefoxitin– ClindamycinClindamycin– MetronidazoleMetronidazole– ChloramphonicoleChloramphonicole

IntroductionIntroductionFever Work-UpFever Work-Up

Automatic set orderAutomatic set order Repeated several times within 24 Repeated several times within 24

hourshours Time consumingTime consuming CostlyCostly Disruptive and patient’s discomfortDisruptive and patient’s discomfort Considerable blood lossConsiderable blood loss Unneeded radiationUnneeded radiation

Practice ParametersPractice ParametersGoalsGoals

Rational consumption of Rational consumption of resourcesresources

Efficient evaluationEfficient evaluation

The Search for the The Search for the Underlying Cause of Underlying Cause of

Fever?Fever?

What temperature should elicit an What temperature should elicit an evaluation?evaluation?

When are blood cultures warrantedWhen are blood cultures warranted When should intravascular catheters be When should intravascular catheters be

cultured or removedcultured or removed When are cultures of respiratory When are cultures of respiratory

secretions, urine, stool, or CSF warrantedsecretions, urine, stool, or CSF warranted When are radiological studies warrantedWhen are radiological studies warranted

Initiating Fever EvaluationInitiating Fever EvaluationDefinition of FeverDefinition of Fever

Arbitrary: core temperature Arbitrary: core temperature >38.0°C, or two consecutive >38.0°C, or two consecutive elevation of > 38.3°Celevation of > 38.3°C

The lower the temperature that is The lower the temperature that is used to define fever, the more used to define fever, the more sensitive and less specific the sensitive and less specific the indicator is for detecting an indicator is for detecting an infectious etiologyinfectious etiology

Initiating Fever EvaluationInitiating Fever Evaluation Normal Body TemperatureNormal Body Temperature

Normal body temperature is Normal body temperature is 37.0°C37.0°C

Varies by 0.5°C to 1°C according to Varies by 0.5°C to 1°C according to circadian rhythm and menstrual circadian rhythm and menstrual cyclecycle

Exercise can increase temperature Exercise can increase temperature by 2°C to 3°Cby 2°C to 3°C

Initiating Fever EvaluationInitiating Fever Evaluation Variation of Temperature in ICUVariation of Temperature in ICU

Specialized mattressesSpecialized mattresses Hot lightsHot lights Air conditioningAir conditioning Cardiopulmonary bypassCardiopulmonary bypass Peritoneal lavagePeritoneal lavage Dialysis and continuous hemofiltrationDialysis and continuous hemofiltration Drugs altering thermoregulatory Drugs altering thermoregulatory

mechanismsmechanisms

Initiating Fever EvaluationInitiating Fever Evaluation Non-infectious Causes of Fever can be Life-Non-infectious Causes of Fever can be Life-

threateningthreatening

Adrenal insufficiencyAdrenal insufficiency Thyroid stormThyroid storm Malignant hyperthermiaMalignant hyperthermia Heat strokeHeat stroke

Initiating Fever EvaluationInitiating Fever Evaluation Infected Patient but AfebrileInfected Patient but Afebrile

ElderlyElderly Open abdominal woundsOpen abdominal wounds Large burnsLarge burns Extracorporeal membrane Extracorporeal membrane

oxygenationoxygenation Patients taking anti-inflammatory Patients taking anti-inflammatory

or anti-pyretic drugsor anti-pyretic drugs

Initiating Fever EvaluationInitiating Fever Evaluation Temperature MeasurementTemperature Measurement

Most accurately measured using Most accurately measured using intravascular or bladder thermistorintravascular or bladder thermistor

Mouth, rectal or external auditory Mouth, rectal or external auditory measurements using electronic measurements using electronic probes is acceptable in appropriate probes is acceptable in appropriate patientspatients

Axillary measurements should not Axillary measurements should not be used be used

Initiating Fever EvaluationInitiating Fever Evaluation Clinical EvaluationClinical Evaluation

A new onset of temperature to or A new onset of temperature to or above 38.3C is reasonable trigger for above 38.3C is reasonable trigger for a clinical assessment but not a clinical assessment but not necessarily a laboratory or necessarily a laboratory or radiological evaluationradiological evaluation

Clinical assessment may reveal a Clinical assessment may reveal a purulent wound or phlebitic leg, then purulent wound or phlebitic leg, then diagnosis and therapy for that diagnosis and therapy for that infectious process should commenceinfectious process should commence

Bacterial Synergistic Bacterial Synergistic GangreneGangrene

Anaerobic CellulitisAnaerobic Cellulitis

Initiating Fever EvaluationInitiating Fever Evaluation Obtaining Blood CulturesObtaining Blood Cultures

Skin PreperationSkin Preperation

The site of venipunture should be cleaned The site of venipunture should be cleaned with either 10% povidone iodine or 1-2% with either 10% povidone iodine or 1-2% tincture of iodine. If the patient is allergic to tincture of iodine. If the patient is allergic to iodine alcohol 70% swabs should be usediodine alcohol 70% swabs should be used

The access to intravascular device and to the The access to intravascular device and to the stopper on the culture bottle should be stopper on the culture bottle should be cleaned with 70% alcoholcleaned with 70% alcohol

Iodophors must be allowed to dry to provide Iodophors must be allowed to dry to provide maximal antiseptic activitymaximal antiseptic activity

Initiating Fever EvaluationInitiating Fever Evaluation Obtaining Blood CulturesObtaining Blood Cultures

Blood VolumeBlood Volume

One blood culture is defined as a One blood culture is defined as a sample of blood drawn at a single time sample of blood drawn at a single time at a single siteat a single site

One milliliter of blood is needed per five One milliliter of blood is needed per five milliliter of mediamilliliter of media

5 ml of blood is injected into each of 5 ml of blood is injected into each of two or three bottles for routine blood two or three bottles for routine blood culture culture

10-15 ml per one set of blood cultre10-15 ml per one set of blood cultre

Initiating Fever EvaluationInitiating Fever Evaluation Obtaining Blood CulturesObtaining Blood Cultures

Number of Cultures & SitesNumber of Cultures & Sites

Two cultures 10 minutes apart after the Two cultures 10 minutes apart after the onset of fever. Culture should not be onset of fever. Culture should not be repeated till 24 hours passedrepeated till 24 hours passed

Each culture should be drawn by separate Each culture should be drawn by separate venipuncturevenipuncture

One culture can be obtained from the One culture can be obtained from the most recently inserted catheter in case most recently inserted catheter in case venipuncture is difficult (the second B/C venipuncture is difficult (the second B/C from a venipuncture site)from a venipuncture site)

Initiating Fever EvaluationInitiating Fever EvaluationCXR & SputumCXR & Sputum

Chest x-ray in an erect sitting Chest x-ray in an erect sitting position during deep inspirationposition during deep inspiration

The absence of infiltrates, masses The absence of infiltrates, masses or effusion does not exclude or effusion does not exclude pneumonia, abscess or empyemapneumonia, abscess or empyema

Respiratory secretion obtained by Respiratory secretion obtained by suctioned or expectorated sputum suctioned or expectorated sputum is adequate for initial evaluationis adequate for initial evaluation

Initiating Fever EvaluationInitiating Fever EvaluationUrinalysis and Urine CultureUrinalysis and Urine Culture

Obtain urine for culture and for Obtain urine for culture and for determination of the presence of pyuriadetermination of the presence of pyuria

Patients who have Foley catheter in place Patients who have Foley catheter in place should have urine collected from the urine should have urine collected from the urine port of the catheter and not from the port of the catheter and not from the drainage bagdrainage bag

Urine should be transported to the laboratory Urine should be transported to the laboratory rapidly to avoid bacterial multiplication, rapidly to avoid bacterial multiplication, otherwise should be refrigeratedotherwise should be refrigerated

Initiating Fever EvaluationInitiating Fever EvaluationStool ExaminationStool Examination

Mandatory when more than 2 stools per day Mandatory when more than 2 stools per day conform to the container in which they are placed conform to the container in which they are placed in a patient at risk for C-difficilein a patient at risk for C-difficile

Stool should be sent for WBC or lactoferrin latex Stool should be sent for WBC or lactoferrin latex agglutination testagglutination test

Stool should be sent for c-diff assay for at least 2 Stool should be sent for c-diff assay for at least 2 times in 24 hourstimes in 24 hours

Stool should not be sent for other enteric pathogens Stool should not be sent for other enteric pathogens unless the patient is HIV or present to the hospital unless the patient is HIV or present to the hospital with diarrheawith diarrhea

Infectious Causes of FeverInfectious Causes of Fever

Catheter-related InfectionsCatheter-related Infections ICU acquired PneumoniaICU acquired Pneumonia Urinary Tract InfectionUrinary Tract Infection Pseudomembraneous colitisPseudomembraneous colitis Wound InfectionWound Infection SinusitisSinusitis Acaculous cholecystitisAcaculous cholecystitis

Vascular Devices & feverVascular Devices & fever

Localized infectionLocalized infection– Exit site infectionExit site infection– Tunnel infectionTunnel infection

Systemic infectionSystemic infection Allergic reactionAllergic reaction

Relative Risks of CR-BSIRelative Risks of CR-BSI Duration of catheter in placeDuration of catheter in place Anatomic site of insertionAnatomic site of insertion Type of the device:Type of the device:

– Catheter compositionCatheter composition– A-Line, Central line, Hickman’s catheterA-Line, Central line, Hickman’s catheter– Regular vs antibiotic-impregnated catheterRegular vs antibiotic-impregnated catheter

Patient populationPatient population Techniques used in insertion and maintenanceTechniques used in insertion and maintenance Frequency of manipulationFrequency of manipulation

Duration of Catheter UseDuration of Catheter UseOptimal Time for Catheter Removal?Optimal Time for Catheter Removal?

The incidence of CR-BSI is directly The incidence of CR-BSI is directly proportional to the length of time proportional to the length of time the catheter is usedthe catheter is used

The risk that any catheter may The risk that any catheter may cause CR-BSI is low if the catheter cause CR-BSI is low if the catheter is removed within 3 daysis removed within 3 days

The optimal time for catheter The optimal time for catheter removal is unknownremoval is unknown

Anatomic Site of InsertionAnatomic Site of InsertionIncidence of Catheter Colonization: Incidence of Catheter Colonization:

Kemp and associatesKemp and associates

Femoral line: 36%Femoral line: 36% Internal jugular: 17%Internal jugular: 17% Subclavian: 5%Subclavian: 5%

Type of the DeviceType of the DeviceRisk of CR-BSIRisk of CR-BSI

Short-term noncuffed central Short-term noncuffed central venous catheters: 5-10 cases per venous catheters: 5-10 cases per 1000 catheter days1000 catheter days

Peripheral IV catheter: less than Peripheral IV catheter: less than 0.2 cases per 1000 catheter days0.2 cases per 1000 catheter days

Permanent surgically implanted Permanent surgically implanted central device: 2 bacteremias per central device: 2 bacteremias per 1000 catheter days1000 catheter days

Catheter Related InfectionsCatheter Related InfectionsDefinitionsDefinitions

Colonized CatheterColonized Catheter

Positive culture from the catheter tip or Positive culture from the catheter tip or intracutaneous segment without evidence intracutaneous segment without evidence of systemic infectionof systemic infection

Semiquantitative culture of 15 or more CFU Semiquantitative culture of 15 or more CFU is used to consider culture as positiveis used to consider culture as positive

Values of less than 15 CFU are regarded as Values of less than 15 CFU are regarded as negative culture, contaminant, or negative culture, contaminant, or insignificant infection requiring no therapyinsignificant infection requiring no therapy

Catheter Related InfectionsCatheter Related InfectionsDefinitionsDefinitions

Catheter-Related Bloodstream InfectionCatheter-Related Bloodstream Infection

A positive catheter culture A positive catheter culture 15 CFU 15 CFU with concomitant positive blood culturewith concomitant positive blood culture

A quantitative blood culture drawn A quantitative blood culture drawn from the catheter shows marked step-from the catheter shows marked step-up in concentration of organisms (ten-up in concentration of organisms (ten-fold or greater) as compared with fold or greater) as compared with peripherally drawn quantitative blood peripherally drawn quantitative blood cultureculture

No other identifiable source of infectionNo other identifiable source of infection

Catheter Related InfectionsCatheter Related InfectionsDefinitionsDefinitions

Infusate-Related Bloodstream InfectionInfusate-Related Bloodstream Infection

Isolation of the same organism Isolation of the same organism from the infusate and from from the infusate and from separate percutaneous peripheral separate percutaneous peripheral blood cultureblood culture

No other identifiable source of No other identifiable source of infection infection

Catheter Related InfectionsCatheter Related InfectionsDefinitionsDefinitions

Local Catheter-Related InfectionLocal Catheter-Related Infection

Growth of 15 or more CFU from a Growth of 15 or more CFU from a catheter specimen by catheter specimen by semiquantitative culturesemiquantitative culture

Local signs of inflammation: Local signs of inflammation: erythema, swelling, tenderness, erythema, swelling, tenderness, purulent materialpurulent material

Negative peripheral blood cultureNegative peripheral blood culture

When the Catheter Should be When the Catheter Should be Removed in a Febrile Patient?Removed in a Febrile Patient?

No other identifiable SourceNo other identifiable Source

For stable patients with fever, there is For stable patients with fever, there is no necessity to remove or change all no necessity to remove or change all indwelling catheters unless CR-BSI or indwelling catheters unless CR-BSI or Local infection is documentedLocal infection is documented

If patients are in shock, manifest If patients are in shock, manifest peripheral embolization, DIC or ARDS, peripheral embolization, DIC or ARDS, removal of all intravascular catheters removal of all intravascular catheters and reinsertion at new sites is and reinsertion at new sites is indicated.indicated.

Pulmonary Infections & Pulmonary Infections & FeverFever

Diagnostic StrategiesDiagnostic Strategies

Empirical strategy based only on Empirical strategy based only on clinical evaluationclinical evaluation

Invasive strategy based on fiberoptic Invasive strategy based on fiberoptic bronchoscopy and quantitative cultures bronchoscopy and quantitative cultures of distal uncontaminated pulmonary of distal uncontaminated pulmonary secretionssecretions

Intermediate strategy based on Intermediate strategy based on quantitative culture of quantitative culture of nonbronchoscopic samplenonbronchoscopic sample

Diagnostic Strategy based Diagnostic Strategy based on Clinical Evaluation onlyon Clinical Evaluation only

Fever, cough, sputum production, new Fever, cough, sputum production, new pulmonary infiltrate and elevated pulmonary infiltrate and elevated leukocyte count.leukocyte count.

May not be present in the hospitalized May not be present in the hospitalized patients with nosocomial pneumoniapatients with nosocomial pneumonia

May be present but may not be caused May be present but may not be caused by pneumonia: CHF, ARDS, atelectasisby pneumonia: CHF, ARDS, atelectasis

Diagnostic Strategy based Diagnostic Strategy based on Clinical Evaluation onlyon Clinical Evaluation only

Clinical Variables Pneumonia No Pneumonia

Fever 100% 80%

Leukocytosis 100% 80%

Pathogen in sputum 86% 70%

Asymmetric infiltrates onCXR

57% 30%

Response to Abx 2/14 3/10

Andrews et al, chest 1981;80:254-258

Diagnostic Strategy based Diagnostic Strategy based on Clinical Evaluation onlyon Clinical Evaluation only

Totalcases

In error Correct Misdiagnosed

18 4 9 5

Andrews et al, chest 1981;80:254-258

Autopsy Results

Chastre et al. Evaluation of bronchoscopic techniques for thediagnosis of nosocomial pneumonia. Am J Respir Crit Care Med 1995; 152:231-240

Diagnostic Strategy based Diagnostic Strategy based on Invasive Evaluationon Invasive Evaluation

Bronchoalveolar Lavage

Sensitivity Specificity

BAL 91% 78%

Chastre et al. Evaluation of bronchoscopic techniques for thediagnosis of nosocomial pneumonia. Am J Respir Crit Care Med 1995; 152:231-240

Diagnostic Strategy based on Invasive Diagnostic Strategy based on Invasive EvaluationEvaluation

Protected Brush SpecimenProtected Brush Specimen

Sensitivity Specificity

PSB 82% 89%

Diagnostic Strategy based on Invasive Diagnostic Strategy based on Invasive Evaluation Evaluation

Protected Brush SpecimenProtected Brush SpecimenDrawbacks: False Negative ResultsDrawbacks: False Negative Results

Bronchoscopy performed at an early Bronchoscopy performed at an early stage of infection with bacterial burden stage of infection with bacterial burden below the concentration necessary to below the concentration necessary to reach diagnostic significancereach diagnostic significance

Specimens obtained from unaffected Specimens obtained from unaffected segmentssegments

Specimens incorrectly processedSpecimens incorrectly processed Specimens obtained after initiation of a Specimens obtained after initiation of a

new antimicrobial therapynew antimicrobial therapy

Represents a good alternative in Represents a good alternative in patients with very unstable conditions patients with very unstable conditions and in patients for whom it is not and in patients for whom it is not possible to delay the initiation of possible to delay the initiation of antimicrobial treatment while awaiting antimicrobial treatment while awaiting bronchoscopybronchoscopy

Diagnosis can be missed, especially in Diagnosis can be missed, especially in the case of upper lobes or left lung the case of upper lobes or left lung infectioninfection

Intermediate Strategy Based on Intermediate Strategy Based on Quantitative Culture of Quantitative Culture of

Nonbronchoscopic SamplesNonbronchoscopic SamplesQuantitative Cultures of Nonbronchoscopic Distal

Protected Specimen

68% VS 84%

Jourdain et al. Role of quantitative cultures of Endotracheal aspirates for the diagnosis of nosocomial pneumonia. Am J Resp Crit Care Med 1995; 152:241-246

Quantitative Cultures of Endotracheal aspirates

Intermediate Strategy Based on Intermediate Strategy Based on Quantitative Culture of Quantitative Culture of

Nonbronchoscopic SamplesNonbronchoscopic Samples

Study CutoffValues

Sensitivity Specificity

Marquette et al 106 82% 83%

El-Ebiary et al 105 70% 72%

Diarrhea & Fever in ICUDiarrhea & Fever in ICU

Diarrhea is caused by enteral Diarrhea is caused by enteral feeding or drugsfeeding or drugs

The only common enteric cause of The only common enteric cause of fever in the ICU is fever in the ICU is Clostridium Clostridium difficiledifficile

C. difficileC. difficile accounts for about 25% accounts for about 25% of all cases of antibiotic-related of all cases of antibiotic-related diarrhea diarrhea

Pseudomembraneous Pseudomembraneous ColitisColitis

Methods SensitivityStool WBC 40%Lactoferrin latexagg. test

75%

EIA toxin 72% 1st sample84% 2nd sample

Tissue Cx toxin 81% 1st sample91% 2nd sample

Sigmoidoscopy 71% severe disease23% mild disease

Methylene Blue StainMethylene Blue Stain

Cytotoxin Effect on Baby Cytotoxin Effect on Baby Hamster kidney CellsHamster kidney Cells

UTI & Fever in ICUUTI & Fever in ICU

The presence of pyuria can help The presence of pyuria can help establish the importance of urinary establish the importance of urinary bacteriabacteria

Leukocyte esterase dipstick test is Leukocyte esterase dipstick test is easy and simpleeasy and simple

Gram stain of a centrifuged urine Gram stain of a centrifuged urine sediment may provide clues to the sediment may provide clues to the type of microorganisms presenttype of microorganisms present

Other Causes of Fever in Other Causes of Fever in ICUICU

RespiratoryRespiratory

TracheobronchitisTracheobronchitis EmpyemaEmpyema Lung abscessLung abscess SinusitisSinusitis

Other Causes of Fever in Other Causes of Fever in ICUICU

Wound & Soft TissueWound & Soft Tissue

Wound infectionWound infection Decubitus ulcersDecubitus ulcers CellulitisCellulitis Deep-seated abscess: sub-Deep-seated abscess: sub-

diaphragmaticdiaphragmatic

Other Causes of Fever in Other Causes of Fever in ICUICU

GastrointestinalGastrointestinal

Ischemic colitisIschemic colitis Acalculous cholecystitisAcalculous cholecystitis CholangitisCholangitis Transfusion-related hepatitis: CMV, Transfusion-related hepatitis: CMV,

hepatitis C, and hepatitis Bhepatitis C, and hepatitis B Intraabdominal abscessIntraabdominal abscess DiverticulitisDiverticulitis

Other Causes of Fever in Other Causes of Fever in ICUICU

Prosthetic DevicesProsthetic Devices

Cardiac valve/pacemakerCardiac valve/pacemaker Joint replacement prosthesisJoint replacement prosthesis Peritoneal dialysis catheterPeritoneal dialysis catheter CNS intraventricular shuntCNS intraventricular shunt

Non-Infectious Source of Fever in Non-Infectious Source of Fever in ICUICU

DrugsDrugs

Antibiotics: B-lactam agentsAntibiotics: B-lactam agents Anti-epileptic drugs: phenytoinAnti-epileptic drugs: phenytoin Antiarrythmics: quinidine and Antiarrythmics: quinidine and

procainamideprocainamide Antihypertensive: methyldopaAntihypertensive: methyldopa

Non-Infectious Source of Fever in Non-Infectious Source of Fever in ICUICU

Post-operativePost-operative

Up till 72 hours postoperativeUp till 72 hours postoperative AtelectasisAtelectasis Post-pericardiotomy syndromePost-pericardiotomy syndrome

Non-Infectious Source of Fever in Non-Infectious Source of Fever in ICUICU

Vascular ConditionsVascular Conditions

Deep venous thrombophlebitisDeep venous thrombophlebitis Pulmonary embolism and infarctionPulmonary embolism and infarction Bowel ischemiaBowel ischemia Hemorrhage into CNS, Hemorrhage into CNS,

retroperitonium, joint, lung, and retroperitonium, joint, lung, and adrenalsadrenals

Myocardial infarction and Dressler’s Myocardial infarction and Dressler’s syndromesyndrome

Non-Infectious Source of Fever in Non-Infectious Source of Fever in ICUICU

Inflammatory ConditionsInflammatory Conditions

Reaction to blood productsReaction to blood products Proliferative phase of ARDSProliferative phase of ARDS Infusion of interleukin-2, granulocyte Infusion of interleukin-2, granulocyte

macrophage colony stimulating factor, macrophage colony stimulating factor, and granulocyte colony stimulating factorand granulocyte colony stimulating factor

Postpericardiotomy syndromePostpericardiotomy syndrome PancreatitisPancreatitis VasculitisVasculitis

Non-Infectious Source of Fever in Non-Infectious Source of Fever in ICUICU

Metabolic ConditionsMetabolic Conditions

Heat strokeHeat stroke Malignant hyperthermiaMalignant hyperthermia Neuroleptic malignant syndromeNeuroleptic malignant syndrome Adrenal insufficiencyAdrenal insufficiency Alcohol withdrawalAlcohol withdrawal SeizuresSeizures HyperthyroidismHyperthyroidism

Non-Infectious Source of Fever in Non-Infectious Source of Fever in ICUICU

NeoplasmsNeoplasms

LymphomaLymphoma Renal cell carcinomaRenal cell carcinoma HepatomaHepatoma Malignant metastatic to the liverMalignant metastatic to the liver Colon carcinomaColon carcinoma