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Life-Threatening InfectionsLife-Threatening Infections

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ObjectivesObjectives

• Recognize predisposing conditions for infection• Identify clinical manifestations of infection• Understand the use of the laboratory evaluation

in suspected infection• Outline principles for empiric antibiotic therapy• List antimicrobial strategies for specific

infections

• Recognize predisposing conditions for infection• Identify clinical manifestations of infection• Understand the use of the laboratory evaluation

in suspected infection• Outline principles for empiric antibiotic therapy• List antimicrobial strategies for specific

infections

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Infection / Inflammation Principles

Infection / Inflammation Principles

• Infection is a cause, comorbidity, and/or consequence of critical illness or injury

• Systemic response may produce or compound effects of other injury or illness

• Infection is a cause, comorbidity, and/or consequence of critical illness or injury

• Systemic response may produce or compound effects of other injury or illness

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SCCM / ACCP ConsensusConference Definitions

SCCM / ACCP ConsensusConference Definitions

• Infection• Systemic inflammatory response

syndrome (SIRS)• Sepsis• Severe sepsis• Septic shock

• Infection• Systemic inflammatory response

syndrome (SIRS)• Sepsis• Severe sepsis• Septic shock

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Principles of DiagnosisPrinciples of Diagnosis

• Assessment of risk factors

• Systemic and site-specific signs and symptoms

• Laboratory data

• Additional studies – focused by signs, symptoms and supportive data

• Assessment of risk factors

• Systemic and site-specific signs and symptoms

• Laboratory data

• Additional studies – focused by signs, symptoms and supportive data

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Principles of DiagnosisPrinciples of Diagnosis

• Epidemiologic setting– Community–Modified community– Hospital

• Predisposing conditions– Extremes of age– Immunocompromise– Prosthetic devices– Invasive procedures

• Epidemiologic setting– Community–Modified community– Hospital

• Predisposing conditions– Extremes of age– Immunocompromise– Prosthetic devices– Invasive procedures

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Systemic Manifestations of Infection

Systemic Manifestations of Infection

• Fever (or normo-/hypothermia)

• Chills

• Tachypnea/dyspnea

• Nausea/vomiting

• Tachycardia

• Hypotension

• Hypoperfusion

• Fever (or normo-/hypothermia)

• Chills

• Tachypnea/dyspnea

• Nausea/vomiting

• Tachycardia

• Hypotension

• Hypoperfusion

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Site-Specific Manifestations of Infection

Site-Specific Manifestations of Infection

• Central nervous system

• Respiratory tract

• Abdomen

• Urinary tract

• Skin/wound

• Central nervous system

• Respiratory tract

• Abdomen

• Urinary tract

• Skin/wound

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Laboratory Evaluation Laboratory Evaluation

• White blood cell count

• Coagulation abnormalities

• Glucose metabolism

• Acid-base status

• Renal function

• Hepatic function

• White blood cell count

• Coagulation abnormalities

• Glucose metabolism

• Acid-base status

• Renal function

• Hepatic function

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Microbiological StudiesMicrobiological Studies

• Gram’s and other special stains

• Cultures before antibiotics

• Blood cultures( 2 sets with 10-15 ml)

• Sputum/tracheal secretions

• Semiquantitative urine culture

• Catheter exit site/intradermal segment

• Gram’s and other special stains

• Cultures before antibiotics

• Blood cultures( 2 sets with 10-15 ml)

• Sputum/tracheal secretions

• Semiquantitative urine culture

• Catheter exit site/intradermal segment

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Other StudiesOther Studies• Chest– Radiograph– Thoracentesis

• Central nervous system– Lumbar puncture– CT or MRI

• Abdomen/retroperitoneum– Radiograph for free air– CT or ultrasound

• Chest– Radiograph– Thoracentesis

• Central nervous system– Lumbar puncture– CT or MRI

• Abdomen/retroperitoneum– Radiograph for free air– CT or ultrasound

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Principles of Antibiotic SelectionPrinciples of Antibiotic Selection

• Suspected pathogen(s) and site

• Gram ‘s stain or culture results, if available

• Assessment for antimicrobial resistance

• Comorbid conditions

• Parenteral administration in critically ill

• Suspected pathogen(s) and site

• Gram ‘s stain or culture results, if available

• Assessment for antimicrobial resistance

• Comorbid conditions

• Parenteral administration in critically ill

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MeningitisMeningitis• Community-acquired– Streptococcus pneumoniae– Neisseria meningitidis

• Immunocompromise, neurosurgery, hospital-acquired– Staphylococcus aureus– Listeria– Gram-negative bacteria

• Community-acquired– Streptococcus pneumoniae– Neisseria meningitidis

• Immunocompromise, neurosurgery, hospital-acquired– Staphylococcus aureus– Listeria– Gram-negative bacteria

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Antibiotics for MeningitisAntibiotics for Meningitis

• Ceftriaxone or cefotaxime• High dose penicillin G – N. meningitidis• Ampicillin or

trimethoprim/sulfamethoxazole – Listeria• Nafcillin, oxacillin or vancomycin –

Staphylococcus• Third-generation cephalosporin – gram

negative bacilli

• Ceftriaxone or cefotaxime• High dose penicillin G – N. meningitidis• Ampicillin or

trimethoprim/sulfamethoxazole – Listeria• Nafcillin, oxacillin or vancomycin –

Staphylococcus• Third-generation cephalosporin – gram

negative bacilli

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Other CNS InfectionsOther CNS Infections

• Encephalitis– Herpes simplex – acyclovir

• Brain abscess– Polymicrobial– Penicillin, metronidazole, and third-

generation cephalosporin– Vancomycin if penicillin-allergic

• Encephalitis– Herpes simplex – acyclovir

• Brain abscess– Polymicrobial– Penicillin, metronidazole, and third-

generation cephalosporin– Vancomycin if penicillin-allergic

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Community-Acquired Pneumonia(Immunocompetent)

Community-Acquired Pneumonia(Immunocompetent)

• Organisms– S. pneumoniae,

H. influenzae• Antibiotics– Macrolide + second-/third-

generation cephalosporin– Ampicillin/sulbactam– Legionella coverage

• Organisms– S. pneumoniae,

H. influenzae• Antibiotics– Macrolide + second-/third-

generation cephalosporin– Ampicillin/sulbactam– Legionella coverage

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Community-Acquired Pneumonia(Immunocompromised)

Community-Acquired Pneumonia(Immunocompromised)

• Pneumocystis carinii–Trimethoprim/sulfamethoxazole–Pentamidine–Consider steroids if hypoxemic

• Fungal–Amphotericin B

• Pneumocystis carinii–Trimethoprim/sulfamethoxazole–Pentamidine–Consider steroids if hypoxemic

• Fungal–Amphotericin B

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Nosocomial or Ventilator-Associated Pneumonia

Nosocomial or Ventilator-Associated Pneumonia

• Aminoglycoside or fluoroquinolone + third-generation cephalosporin

• Ticarcillin/clavulanate or piperacillin/tazobactam• Imipenem-cilastatin• Two antipseudomonal agents• Vancomycin for staphylococci– Linezolid or quinupristin-dalfopristin for

resistance or intolerance

• Aminoglycoside or fluoroquinolone + third-generation cephalosporin

• Ticarcillin/clavulanate or piperacillin/tazobactam• Imipenem-cilastatin• Two antipseudomonal agents• Vancomycin for staphylococci– Linezolid or quinupristin-dalfopristin for

resistance or intolerance

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Abdominal InfectionsAbdominal Infections

• Surgical consultation

• Aerobic and anaerobic pathogens

• Monotherapy (if Pseudomonas unlikely)

– Imipenem or meropenem

–Piperacillin/tazobactam

–Ticarcillin/clavulanate

• Surgical consultation

• Aerobic and anaerobic pathogens

• Monotherapy (if Pseudomonas unlikely)

– Imipenem or meropenem

–Piperacillin/tazobactam

–Ticarcillin/clavulanate

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Abdominal InfectionsAbdominal Infections

• Combination therapy

– Ampicillin + clindamycin + aztreonam

– Ampicillin/sulbactam + aminoglycoside

– Ticarcillin/clavulanate, imipenem, piperacillin/tazobactam + aminoglycoside

– Cefoxitin or cefotetan + aminoglycoside

– Quinolone + metronidazole or clindamycin

• Combination therapy

– Ampicillin + clindamycin + aztreonam

– Ampicillin/sulbactam + aminoglycoside

– Ticarcillin/clavulanate, imipenem, piperacillin/tazobactam + aminoglycoside

– Cefoxitin or cefotetan + aminoglycoside

– Quinolone + metronidazole or clindamycin

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Urinary Tract InfectionsUrinary Tract Infections

• Third-generation cephalosporin

• Quinolone

• Trimethoprim/sulfamethoxazole

• Aztreonam

• Consider complications

• Candiduria

• Third-generation cephalosporin

• Quinolone

• Trimethoprim/sulfamethoxazole

• Aztreonam

• Consider complications

• Candiduria

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Cutaneous InfectionsCutaneous Infections

• Organisms – S. aureus, -hemolytic streptococci, H. influenzae, C. perfringens

• Antibiotics– Cefazolin– Nafcillin– Vancomycin– Penicillin G (C. perfringens and -

hemolytic streptococci)• Wound toxic shock

• Organisms – S. aureus, -hemolytic streptococci, H. influenzae, C. perfringens

• Antibiotics– Cefazolin– Nafcillin– Vancomycin– Penicillin G (C. perfringens and -

hemolytic streptococci)• Wound toxic shock

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Necrotizing FasciitisNecrotizing Fasciitis

• Immediate surgical consult for debridement

• Polymicrobial infection

• Antibiotics

– Ampicillin/sulbactam

– Ticarcillin/clavulanate

– Piperacillin + aminoglycoside + clindamycin

– Imipenem

• Immediate surgical consult for debridement

• Polymicrobial infection

• Antibiotics

– Ampicillin/sulbactam

– Ticarcillin/clavulanate

– Piperacillin + aminoglycoside + clindamycin

– Imipenem

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Vascular Catheter InfectionsVascular Catheter Infections

• Remove catheter with systemic complications or exit site findings

• Coagulase-negative staphylococci– Catheter removal only– immunocompetent or

no symptoms– Vancomycin – compromised or symptoms

• S. aureus – Oxacillin, vancomycin• Gram-negative organisms – add aminoglycoside

or third-generation cephalosporin

• Remove catheter with systemic complications or exit site findings

• Coagulase-negative staphylococci– Catheter removal only– immunocompetent or

no symptoms– Vancomycin – compromised or symptoms

• S. aureus – Oxacillin, vancomycin• Gram-negative organisms – add aminoglycoside

or third-generation cephalosporin

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Immunocompromised or Neutropenic Patients

Immunocompromised or Neutropenic Patients

• Third- or fourth-generation cephalosporin + aminoglycoside

• Imipenem or meropenem

• Ticarcillin/clavulanate

• Piperacillin/tazobactam

• Vancomycin if gram-positive organisms likely

• Third- or fourth-generation cephalosporin + aminoglycoside

• Imipenem or meropenem

• Ticarcillin/clavulanate

• Piperacillin/tazobactam

• Vancomycin if gram-positive organisms likely

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Other InfectionsOther Infections

• Antibiotic-associated colitis–Clostridium difficile infection–Discontinue implicated antibiotic–Oral regimen with metronidazole

• Fungal disease–Amphotericin B preferred–Fluconazole in less severely ill

• Antibiotic-associated colitis–Clostridium difficile infection–Discontinue implicated antibiotic–Oral regimen with metronidazole

• Fungal disease–Amphotericin B preferred–Fluconazole in less severely ill

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Pediatric Considerations – Meningitis

Pediatric Considerations – Meningitis

• Neonate: Group B streptococci, E. coli,

L. monocytogenes, Enterococcus• 2 months–2 yrs: S. pneumoniae, H.

influenzae, N. meningitidis, Salmonella• Treatment• Ceftriaxone, cefotaxime• Ampicillin (Listeria, Enterococcus)• Consider dexamethasone

• Neonate: Group B streptococci, E. coli,

L. monocytogenes, Enterococcus• 2 months–2 yrs: S. pneumoniae, H.

influenzae, N. meningitidis, Salmonella• Treatment• Ceftriaxone, cefotaxime• Ampicillin (Listeria, Enterococcus)• Consider dexamethasone

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Serious Infections in Infants and Children

Serious Infections in Infants and Children

•Meningitis

• Epiglottitis

•Bacterial tracheitis

•Retropharyngeal abscess

•Croup

•Meningitis

• Epiglottitis

•Bacterial tracheitis

•Retropharyngeal abscess

•Croup

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Key PointsKey Points