antibiotic use in the icu

Antibiotic Use in the ICU Fever in the ICU Patient • Infection – Most common cause of fever • Noninfectious causes – Unlikely if T>102 0 F (38.9 0 C) – Post-operative atelectasis is unlikely cause of fevers • Unless associated with pneumonia Fever Fever Common Infections in ICU • Pneumonia • Sinusitis • Catheter-related sepsis • C. difficile colitis • Abdominal sepsis • Complicated wound infection • Bacteremia of uncertain source Fever Common Infections in ICU • Pneumonia • Sinusitis • Catheter-related sepsis • C. difficile colitis • Abdominal sepsis • Complicated wound infection • Bacteremia of uncertain source Antibiotics • Drugs chosen based on potential pathogens present • Rotate common, empiric antibiotics every couple of months Pneumonia Community-Acquired Pneumonia Community-Acquired Pneumonia Community-Acquired [...]... Similar to community-acquired – 33% Gram (-) rods Meninigitis Empiric Treatment • Neonate – Ampicillin, 3rd cephalosporin • 1-18 years – 3rd cephalosporin, vancomycin Meninigitis Empiric Treatment • 18 - 60 years – 3rd cephalosporin, vancomycin • > 60 years – Ampicillin, 3rd cephalosporin, vancomycin Meninigitis Empiric Treatment • 3rd cephalosporin – cefotaxime or ceftriaxone – Avoid ceftazidime •... Difficile • One of the most common hospitalacquired infections • 20% of hospitalized patients infected – 2/3 asymptomatic C Difficile Clinical Presentations • Diarrhea without colitis – Most common – Mild diarrhea, +/- abdominal cramps – +/- mild abdominal tenderness, fever, leukocytosis – Usually stops with discontinuation of antibiotics – Specific therapy usually not needed C Difficile Clinical Presentations... 250 mmHg • CXR – Bilateral involvement – Multilobar involvement ↑ size of infiltrate within 48 hrs Pneumonia Hospital-Acquired: Severe pneumonia • Shock – Hypotension – Need for vasopressors • Acute renal failure – Requiring dialysis – Oliguria • < 20 mL/hr • < 80 mL/4 hrs Pneumonia Hospital-Acquired Pneumonia Hospital-Acquired Pneumonia Hospital-Acquired Sinusitis ICU • 85% incidence with nasotracheal... rate with foley – < 3% develop bacteremia • UTI unlikely to cause high fevers/sepsis – Error on the side of treating Meningitis Pathogens • Neonates – Group B strep., Listeria, E coli (Gram-) • 1- 18 years – N meningitidis (> 50% cases), S pneumoniae • H flu - ↓ 87% - 94% with vaccine Meningitis Pathogens • 18 - 60 years – S pneumoniae, N meningitis • > 60 years – S pneumoniae, Listeria, Gram (-) rods... Pathogens similar to nosocomial pneumonia • Dx: CT scan of sinuses • Rx: – Remove nasal tubes, if present – Empiric antibiotics Catheter-Related Sepsis ICU • 5% of central venous lines – Colonization rate = 25% • Lowest rates per subclavian approach – Femoral rate = IJ rate • Pathogens – S aureus, S epi., Gram (-) rods, enterococcus, Candida species UTI ICU • No criteria developed to differentiate UTI from... pseudomembranes – More serious illness – Malaise, abdominal pain, anorexia, moderate to severe diarrhea – Low grade fever, dehydration, lower abdominal tenderness, leukopcytosis C Difficile Clinical Presentations • Pseudomembranous colitis – Similar to colitis but more severe signs/symptoms – More of a sepsis/septic shock picture • Multiple organ involvement • Fulminant colitis – Perforation, colonic ileus, megacolon,... stool sample – (+) C difficile toxin • Sigmoidoscopy typically not used • CT scan confirms pseudomembranes – Thickened colonic walls C Difficile Treatment • Antibiotic of choice – Metronidazole • (500 mg po q8) – Oral vancomycin equally effective • (125 mg po q6) C Difficile Treatment • Severe cases/unable to take po – Metronidazole (+/- oral vancomycin) • (500 mg IV q8) • Indications for surgery (1% -... Pseudomonas – Structural lung disease – Corticosteroid therapy • > 10 mg prednisone/day – Use of broad-spectrum antibiotics • > 7 days in past month – Malnutrition Pneumonia Hospital-Acquired • Mild-to-moderate severity • Severe – Early onset • < 5 days of admission – Late onset • > 5 days of admission Pneumonia Hospital-Acquired: Severe pneumonia • Admission to ICU • Severe respiratory failure – Need for mechanical... take po – Metronidazole (+/- oral vancomycin) • (500 mg IV q8) • Indications for surgery (1% - 3%) – – – – Peritonitis Bacteremia unresponsive to antibiotics Progressive disease despite antibiotics CT scan of significant colonic wall edema Intra-Abdominal Infection Pathogens • Community-acquired – Anaerobes, coloforms [Gram (-)] • Hospital-acquired – Same as above + resistant Gram (-) rods . Antibiotic Use in the ICU Fever in the ICU Patient • Infection – Most common cause of fever • Noninfectious causes – Unlikely if T>102 0 F (38.9 0 C) – Post-operative. wound infection • Bacteremia of uncertain source Fever Common Infections in ICU • Pneumonia • Sinusitis • Catheter-related sepsis • C. difficile colitis • Abdominal sepsis • Complicated wound infection • Bacteremia. unlikely cause of fevers • Unless associated with pneumonia Fever Fever Common Infections in ICU • Pneumonia • Sinusitis • Catheter-related sepsis • C. difficile colitis • Abdominal sepsis • Complicated