{"id":5190,"date":"2011-07-14T20:24:16","date_gmt":"2011-07-14T20:24:16","guid":{"rendered":"http:\/\/crashtext.org\/misc\/infections-in-the-icu.htm\/"},"modified":"2015-03-10T11:27:50","modified_gmt":"2015-03-10T15:27:50","slug":"infections-in-the-icu","status":"publish","type":"post","link":"https:\/\/crashingpatient.com\/intensive-care\/infections-in-the-icu.htm\/","title":{"rendered":"Infections in the Intensive Care Unit"},"content":{"rendered":"

<\/span>Bad Bugs, No Drugs, No Escape<\/span><\/h2>\n

(CID 2009;49:992)<\/p>\n

Enterococcus faecium<\/p>\n

Staph Aureus<\/p>\n

Clostridium Difficile<\/p>\n

Acinetobacter baumannii<\/p>\n

Pseudomonas aeruginosa<\/p>\n

Enterobacteriaceae<\/p>\n

<\/span>Bacterialcidal vs. Bacteriostatic Probably Doesn’t Matter<\/span><\/h2>\n

<\/abbr><\/cite>J. Antimicrob. Chemother. (2015) 70 (2): 382-395.<\/p>\n

<\/span>Extended Spectrum Beta-Lactamases<\/span><\/h2>\n

E. Coli, Klebsiella, other Gram Neg Rods<\/p>\n

Use Meropenem\/Imipenem\/Doripenem<\/p>\n

Do not use cephalosporins of zosyn as the “inoculum effect” may ruin these drugs<\/p>\n

Duration of treatment is the same<\/p>\n

<\/span>Carbapenem Resistant Gram Negative Rods (CREs)<\/span><\/h2>\n
\n
Current Opinion in Infectious Diseases (December 2014 – Volume 27 – Issue 6 – p 479\u2013483)<\/a><\/div>\n
doi: 10.1097\/QCO.0000000000000109<\/div>\n<\/div>\n

Options for treating carbapenem-resistant Enterobacteriaceae<\/p>\n

Retrospective and prospective (nonrandomized noncontrolled) studies provide data regarding the management of infections due to carbapenem-resistant Enterobacteriaceae. The combination of a carbapenem with colistin or high-dose tigecycline or aminoglycoside or even triple carbapenem-containing combinations if the minimum inhibitory concentration (MIC) range of carbapenem (meropenem and imipenem) resistance is 8\u200amg\/l or less seems to have an advantage over monotherapy with either colistin or tigecycline or fosfomycin. For Enterobacteriaceae with MIC for carbapenems over 8\u200amg\/l, combination regimens involve colistin, tigecycline usually administered in a double dose than that suggested by its manufacturer, fosfomycin and aminoglycosides in various combinations.<\/p>\n

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Summary: Suggestions based on the limited literature cannot be made safely. Combination regimens involving carbapenems for Enterobacteriaceae with MICs 8\u200amg\/l or less for carbapenems (in dual combination with colistin or high-dose tigecycline or aminoglycoside or even triple combinations) seem to confer some therapeutic advantage over monotherapy. For Enterobacteriaceae with higher than the above-mentioned MICs, a combination of two or even three antibiotics among colistin, high-dose tigecycline, aminoglycoside and fosfomycin seems to confer decreased mortality.<\/p>\n<\/div>\n<\/div>\n

<\/span>Urinary Tract Infections<\/span><\/h2>\n

Signs and Symptoms<\/p>\n

Pyuria with > 10 WBC per high-power field<\/p>\n

Urine Cx > 100,000 organisms (stop empiric abx if cx negative)<\/p>\n

—-<\/p>\n

<\/span>VRE: A Very Real Emergency Medicine Problem<\/span><\/h3>\n

With increasing prevalence of antimicrobial resistance among bacteria coupled with the lack of novel antimicrobial development, multi-drug resistant bacteria will continue to be problematic [1]. Due to this increased prevalence, it is likely that even in the emergency department, we will see more and more patients with prior cultures or past medical history documentation of multi-drug resistant bacteria, such as vancomycin resistant Enterococcus (VRE). Once we are aware of this information, how should this affect our decision making for treatment of these patients?<\/p>\n

To help address this, assessment of the following clinical questions may be useful:<\/p>\n

1) \u00a0 Is my patient likely to be ill from VRE?<\/strong>
\nEnterococcus is a common colonizing agent of the gastrointestinal tract and may also colonize the genitourinary tract as well as the skin [2]. As a result, care should be taken to determine colonization versus infection if VRE has been isolated.<\/p>\n

In non-critically ill emergency medicine patients, examining for the presence of VRE risk factors may help to guide therapy. Some common risk factors include: [2]<\/p>\n