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

Pneumonia
Community-Acquired



Pneumonia
Community-Acquired
•
Risk factors for 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 ventilation
–
PaO
2
/FIO
2
< 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 ETT
•
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 asymptomatic bacteruria
•
30% colonization 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
•
Hospital-acquired
–
Similar to community-acquired
–

33% Gram (-) rods