{"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":"
(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
<\/abbr><\/cite>J. Antimicrob. Chemother. (2015) 70 (2): 382-395.<\/p>\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 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 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 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 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> 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 In patients who are likely to be ill due to VRE, treatment should be started with an agent likely to be active against the VRE at the site of the infection. In critically ill patients with a past medical history positive for VRE, it is prudent to cover the patient for this organism until proven otherwise. There are no specific recommendations for VRE bacteremia in general; however, the 2009 clinical practice guidelines recommend either intravenous linezolid or daptomycin for the treatment of intravenous catheter-related bacteremia secondary to VRE [3]. Past cultures isolated from previous infections may or may not be what is currently making the patient ill. For serious illness such as bacteremia or endocarditis, consideration of past culture data may be acceptable for select patients such as those who are sent in from an outside facility with recent culture data or a recent hospital visit where current cultures were obtained. For example, if a patient was seen last week with a urinary tract infection from VRE and is now presenting with symptoms of urosepsis, depending upon the clinical picture it may be reasonable to use the culture data from the prior week to base clinical decisions (see Table 1 below for treatment options).<\/p>\n For the more common infection of VRE cystitis, more treatment options may be available. Ideally, we will be able to choose the most narrow, tolerable, and cost-effective antimicrobial coverage for our patients.<\/span>Extended Spectrum Beta-Lactamases<\/span><\/h2>\n
<\/span>Carbapenem Resistant Gram Negative Rods (CREs)<\/span><\/h2>\n
<\/span>Urinary Tract Infections<\/span><\/h2>\n
<\/span>VRE: A Very Real Emergency Medicine Problem<\/span><\/h3>\n
\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\n
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\n<\/strong> 2) \u00a0\u00a0How sick is my patient?\u00a0<\/strong><\/p>\n
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\n<\/strong> 3) \u00a0\u00a0Do I have culture data?\u00a0<\/strong><\/p>\n
\nTable 1<\/span><\/strong>: VRE Treatment Options [2-6]<\/p>\n