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Fever and antibiotics
1. FEVER IN INTENSIVE CARE
UNIT
Dr. Nathan Muluberhan(E M
r e s i d e n t )
August
2017
2. OUTLINE
DEFINITIONS OF TERMS
PATHOGENESIS OF FEVER
SIGNIFICANCE OF FEVER
FEVER IN ICU
INFECTIOUS CAUSE
NON INFECTIOUS CAUSE
3. DEFINITIONS
F E V E R :
elevation of body temperature that exceeds the normal daily
variation and occurs in conjunction with an increase in the hypothalamic set point.
H Y P E R T H E R M I A :
elevation of body temperature in a setting of unchanged the hypothalamic
thermoregulatory center is
HYPERPYREXIA:
an extraordinarily high fever (>41.5ºC)
P Y R O G E N S :
is any substance that causes fever
5. TEMPERATURE MEASUREMENT
Normal body temperature is generally considered to be
37.0°C (98.6°F) with a circadian variation of between 0.5
to 1.0°C.
The Society of Critical Care Medicine define fever in the
ICU as a temperature >38.3°C (>101°F).
6. SIGNIFICANCE OF FEVER
Enhance the resistance of animals to infection
Enhance several parameters of immune
function
some pathogens such as Streptococcus
pneumoniae are inhibited by febrile
temperatures.
a To of 38°C shown to increased survival in
patients with SBP
7. Increase
cardiac output
oxygen consumption
carbon dioxide production
energy expenditure
Poor neurologic outcome in patients with stroke and TBI.
Maternal fever has been suggested to be a cause
fetal malformations and spontaneous abortions
SIGNIFICANCE OF FEVER CONT…
8. FEVER IN ICU
Fever complicates up to 70 % of all ICU admissions.
DIFFERENTIAL:
Fevers between 38.3ºC (101ºF) and 38.8ºC (101.8ºF) may be
infectious or noninfectious.
Fevers between 38.9 (102ºF) and 41ºC (105.8ºF) can be
assumed to be infectious.
Fevers ≥41.1ºC (106ºF) are usually noninfectious.
11. Typically presents with:
a new or progressive pulmonary infiltrate
one or more of the following findings:
fever, purulent tracheobronchial secretions,
leukocytosis,
increased respiratory rate, decreased tidal
volume, increased minute ventilation, and
decreased oxygenation
VENTILATOR-ASSOCIATED PNEUMONIA
CONT…
12. CATHETER-ASSOCIATED SEPSIS
is defined as blood stream infection due to an organism
that has colonized a vascular catheter
Approximately 5% of patients with indwelling vascular
catheters (uncoated) will develop blood stream infection
13. If catheter sepsis is suspected
the catheter should be changed to a new site
Send culture of the catheter tip.
CATHETER-ASSOCIATED SEPSIS
CONT…
14. URINARY TRACT INFECTIONS (UTIS)
account for between 25 to 50% of all infections
Defined as:
the presence of fever >38ºC, SPT, CVAT
Urine culture with
>10(5) cfu/mL irrespective of urinalysis
>10(3) cfu/mL with evidence of pyuria
15. Bacteriuria should be treated following
urinary tract manipulation or surgery
patients with kidney stones & urinary tract
obstruction
Patient with neutropenia
URINARY TRACT INFECTIONS CONT…
16. CLOSTRIDIA DIFFICILE Colitis
About 20% of all hospitalized patients become
“infected” with C difficile
only 1/3 develop diarrhea.
Use of clindamycin, 3rd generation cephalosporin
and fluoroquinolones is the risk factor
Other risk factors:
use of PPI, GI surgery, prolonged ICU stay and tube
feeding
17. Symptoms usually begins shortly after
antibiotics therapy
Clinical spectrum includes:
Colitis, pseudomembranous colitis, fulminant
colitis
Stool assay for toxin A and B by ELISA
Further work up: cytotoxic assay,
sigmoidoscopy and CT scan
CLOSTRIDIA DIFFICILE Colitis
CONT…
18. Stop the offending antibiotics if possible
Provide adequate fluid and electrolytes
Don’t use antimotility agents
If specific rx required use metronidazole
Strict contact isolation of the patient
CLOSTRIDIA DIFFICILE Colitis
CONT…
19. SINUSITIS
sinusitis is common following nasal
intubation
with an incidence of up to 85% after a week of
intubation.
The maxillary sinus is most commonly
involved
20. Major criteria: cough & purulent nasal discharge
Minor criteria: headache or earache, facial or tooth
pain, fever, malodours breath sore throat and
wheezing
Sinusitis on CT
total opacification
the presence of an air fluid level within any of the
paranasal sinuses.
SINUSITIS CONT…
21. MICROBIOLOGY:
Pseudomonas (60%)
Stap. Aureus (33%)
Treatment
Remove all nasal tubes
Drainage (Needle(Maxillary) or surgical (ethmoid and
sphenoid))
Antibiotics
SINUSITIS CONT…
23. DRUG FEVER
It can occur several days after the initiation of the
drug,
can produce high fevers (>38.9ºC) without other
signs.
The true incidence is unknown.
Cause:
Stimulation of heat production(eg. Thyroxine)
Limit of heat dissipation (eg. atropine)
Alter thermoregultion (eg. antihistamines,
24. ADRENAL CRISIS
occurs in patients with previously adrenal
insufficiency who are subjected to a serious
infection or other major stress.
manifestation
Distributive shock is the predominant
fever, nausea, vomiting, abdominal pain, fatigue,
lethargy, hypoglycemia, confusion, or coma
25. EMERGENCY TREATMENT
Adequate fluid resuscitation
Draw blood for electrolytes, glucose, cortisol and
ACTH
Glucocorticoid
Dexamethasone
Hydrocortisone is preferred with known primary
adrenal insufficiency with potassium >6.0 meq/L.
(because of its mineralocorticoid activity)
ADRENAL CRISIS CONT…
26. ACUTE HEMOLYTIC TRANSFUSION
REACTION
A medical emergency that results from the
rapid destruction of donor red blood cells by
recipient antibodies.
Usually due to ABO incompatibility.
Common clinical manifestations
fever, chills, distributive shock, disseminated
intravascular coagulation, and acute kidney injury.
27. Stop the transfusion.
Maintain the patient's airway, blood pressure, and
heart rate.
Begin an infusion of normal saline immediately
Avoid the use of Ringer's lactate solution because its
content of calcium may initiate clotting of any blood
remaining in the intravenous line.
Avoid dextrose- containing solutions because the dextrose
may hemolyze any of the remaining red cells in the line.
ACUTE HEMOLYTIC TRANSFUSION
REACTION CONT…
28. ACALCULOUS CHOLECYSTITIS
0.2 to 1.5 % of patients in ICU
presents with fever, leukocytosis, and vague
abdominal discomfort.
May progress to gangrene and perforation.
have a mortality rate as high as 30 to 40 %
29. ULTRASOUND
Absence of gallstones or sludge
Thickening of the gallbladder wall (>5 mm) with pericholecystic
fluid
A positive Murphy's sign induced by the ultrasound probe
Failure to visualize the gallbladder
Frank perforation of the gallbladder with associated abscess
formation
TREATMENT
broad spectrum antibiotics
cholecystectomy with drainage of any associated abscess
ACALCULOUS CHOLECYSTITIS
CONT…
30. ANTIBIOTIC USE IN INTENSIVE
CARE UNIT
Dr. Nathan Muluberhan(E M
r e s i d e n t )
August 2017
31. OBJECTIVES
principles of antibiotic use
optimize use of antibiotic
multidrug resistant bacteria
To look at the role of novel biomarker
in guiding antibiotic therapy
32. PRINCIPLES OF ANTIBIOTIC
PRESCRIPTION
Send for appropriate investigations (minimum required
for dx, prognosis and follow up) before initiation of
antibiotics
Change in antibiotics would be done after sending fresh
culture
Follow the hospital antibiotics policy. If alternative has
chosen, document the reason
Check for factors which will affects drug choice and
dose(eg. Renal function, interaction and allergy)
Check appropriate dose is prescribed
33. All IV antibiotics may only given for 48-72 hrs without
review
Once culture result available descalate and if not,
document the reason
Emperic therapy initation delay for await of micro report
would be life threatining and mortality rate will be
increased
Antibiotics therapy based on a clinically defined infection
is justified
Rapid tests such as gram stain can help determine
theraputic choice when emperic therapy is required
PRINCIPLES OF ANTIBIOTIC
PRESCRIPTION
34. STRATEGIES TO OPTIMIZE THE USE
OF ANTIMICROBIALS
1. Use of PK/PD parameters for dose
adjustment
2. De-escalation therapy
3. Antibacterial cycling
4. Pre-emptive therapy
37. 1. CONCENTRATION DEPENDENT KILLING ACTIVITY
AND MODERATE TO PROLONGED PERSISTENT
EFFECTS
More rapid killing effect against micro organisms than
low concentrations
Allows the administrations of high doses with widely
separated frequencies of administration
Aminoglycosides, Fluoroquinolones, Metronidazole,
Colistin, Rifampicin, Clindamycin
38. CONCENTRATION DEPENDENT CONT…
AMINOGLYCOSIDES
Doses of these antimicrobials administered to critically ill patients
are frequently insufficient
Rea RS, et al. Suboptimal aminoglycoside dosing in critically ill patients. Ther
Drug Monit 2008; 30: 674-81
FLUOROQUINOLONES
Using a Monte Carlo dosing simulation, doses of 400mg every 8-
12hrs givento 1-2 patients did not reach the necessary killing
concentrations for P.aeruginosa, A.baumannii strains
39. 2. TIME DEPENDENT KILLING ACTIVITY AND
MINIMAL PERSISTENT EFFECTS
Maintain blood concentrations above MIC for
prolonged time periods
These drugs should be given by continuous
infusion
Beta lactams and Linezolid
40. 3. TIME DEPENDENT KILLING ACTIVITY AND
MODERATE TO PROLONGED PERSISTENT EFFECTS
Glycopeptides (Vancomycin, Teicoplanin)
The duration of effect is longer and the possibility of
regrowth of micro-organisms during the dosing
interval is more limited
In humans, AUC/MIC value >350 was an independent
factor associated with clinical success in patients with
S.aureus proven lower respiratory tract infection
Tetracyclines
41. DE-ESCALATION THERAPY
Initial administration of broad spectrum empirical
treatment
To cover pathogens, most frequently related to the
infection
Rapid adjustment of antibacterial treatment
once the causative pathogen has been identified
43. DURATION OF ANTIBIOTIC THERAPY
The optimal duration of antibiotic therapy for
bacteremia is unknown.
some evidence that would suggest that there
is no significant difference in mortality, clinical
and microbiological cure b/n shorter and long
durations
i.e. 5 – 7 days versus 8 -21 days in critically ill
patients with bacteremia.
44. ANTIBACTERIAL CYCLING
The scheduled rotation of one class of
antibacterial
One or more different classes with comparable
spectra of activity
Different mechanisms of resistance
Some weeks and a few months
45. PRE-EMPTIVE THERAPY
The administration of antimicrobials in certain
patients at very high risk of opportunistic infections
before the onset of clinical signs of infection
Developed in hematological patients and/or transplant
recipients
CMV, aspergillosis
In critical illness patients at high risk of candidemia or
invasive candidiasis
46. CANDIDA SCORE
A bedside scoring system for preemptive antifungal
treatment in nonneutropenic critically ill patients with
Candida colonization. Crit Care Med 2006; 34: 730-7
“Candida score” >2.5 accurately selected patients who
would benefit from early antifungal treatment.
Candida score = 0.908* (TPN) + 0.997* (surgery)+ 1.112* (multifocal candida
colonization) + 2.038* (severe sepsis)
1 if present
0 if absent
47. MULTIDRUG RESISTANT
BACTERIA
Increasing prevalence of multidrug-resistant
pathogens in ICUs
CDC Report shows from 1999 and 2006/2007
VRE (from 24.7% to 33.3 % of enterococci isolates)
MRSA (from 53.5 % to 56.2 % of S. aureus isolates)
P. aeruginosa resistant to imipenem (from16.4 to
25.3) or fluoroquinolones (from 23.0 to 30.7) from P.
aeruginosa isolates
48. RISK FACTORS
Older age
Presence of underlying comorbid conditions
higher severity of illness indices
Long hospital courses prior to the ICU admission,
Receipt of antimicrobial therapy prior to the ICU
admission.
Presence of indwelling devices
Recent surgery or other invasive procedure
Frequent manipulation and contact with healthcare
person
49. PREVENTION OF RESISTANCE IN THE ICU
Strategies can be separated into two major
categories:
strategies that attempt to improve the efficacy and
utilization of antimicrobial therapy
infection control measures
50. INFECTION CONTROL MEASURES
good hand hygiene compliance
Active surveillance of patients for
asymptomatic colonization
Institution surveillance for infections with
multidrug-resistant bacteria
Daily chlorhexidine bathing
51. NOVEL BIOMARKERS
PROCALCITONIN
best studied biomarker for guiding antibiotic treatment
duration in the hospital setting.
It’s dynamics within 72 hours after onset of sepsis may be
correlated both with appropriateness of the empirical
antibiotic therapy
integrated in clinical algorithms have been shown to
reduce the duration of antibiotic courses by 25-65% in
hospitalized and more severely ill patients with CAP and
sepsis
52. REFERENCES
Harrison's Principles of Internal Medicine, 19th ed
Up-to-date 21.6
Practice Guidelines for Evaluating New Fever in
Critically Ill Adult Patients. From the National Institutes
of Health, Bethesda, and the Johns Hopkins Hospital and St.
Agnes Hospital
Annual Update in Intensive Care and Emergency
Medicine 2016