Case Scenario
• 17 year old male with PMH cyctinosis complicated with chronic renal failure requiring kidney transplantation X2 that failed and placed on chronic dialysis, patient acquired HBV
• Admitted on January 17, 2010 with:– Fulminant hepatitis secondary to HBV– Acute liver failure– Coagulopathy– Hepatic encephalopathy
Management
• ICU monitoring
• Dialysis continued
• Vitamin K
• Lactulose
• Not candidate for liver transplantation
January 21, 2010
• Respiratory distress
• Fever
• Developed bilateral pulmonary infiltrates
• Intubated
• FiO2 50%, pO2: 65 mm Hg
• Yellowish endotracheal aspirate
• WBC: 12.400
Which of the following organisms is unlikely in this situation?
A. Pseudomonas aerugniosa
B. Escherichia coli
C. Staphylococcus aureus
D. Klebsiella pneumoniae
E. Haemophillus influenza
Common HAP Pathogens in ICU Patients
Others
n=4365
Data from the National Nosocomial Infections Surveillance (NNIS) system (1986–2003) for HAP. Gaynes et al. CID 2005;41:848– 54.
What empiric antibiotics would you choose at this time?
A. Ceftriaxone + metronidazole
B. Ceftazidime + vancomycin
C. Pipercillin/tazobactam + vancomycin
D. Meropenem + vancomycin
E. Ciprofloxacin + amikacin + vancomycin
Hospital Acquired Aspiration PneumoniaAntibiotic Selection
β -lactam/β-lactamase inhibitor (PIP/TAZ) ± AG or Ciprofloxacin ± Glycopeptide Carbapenem (Imipenem, Doripenem or Meriopenem) ± AG or Ciprofloxacin ± Glycopeptide Cefepime ± AG or Ciprofloxacin ± Glycopeptide Ceftazidime ± AG or Ciprofloxacin ± Glycopeptide
ATS combination treatment guidelines for healthcare-acquired pneumonia (HCAP)
ATS/IDS. Am J Respir Crit Care Med 2005;171:388-416
β -lactam/β-lactamaseinhibitor (PIP/TAZ)
OR
Antipseudomonal carbapenem(imipenem or meropenem)
OR
Antipseudomonal cephalosporin (cefipime or ceftazidime)
AntipseudomonalFluoroquinolone(ciprofloxacin or
levofloxacin)
Aminoglycoside(amikacin, gentamicin
or tobramycin)
Vancomycin
+ OR +
Linezolid
January 31, 2010
• Developed acute abdominal pain
• Distended abdomen with tenderness and decreased bowel sounds
Which of the following organisms is least likely in this situation?
A. Bacteroides fragilis
B. Pseudomonas aerugniosa
C. Escherichia coli
D. Klebsiella pneumoniae
E. Enterococcus
Microbiology of Peritonitis
Enterococci
Pseudomonas
S. epidermidis
Candida
B. fragilis group
E. coli
Clostridium spp.
Klebsiella spp.
Streptococcus spp.
Enterococcus spp.
Pseudomonas spp.
E. coli
Klebsiella spp.
Streptococcus spp.
Enterococcus spp.
Other gram-negative bacilli
Tertiary (Polymicrobial)
Secondary (Polymicrobial)
Primary (Monomicrobial)
Barie PS. J Chemother. 1999;11:464-477.LaRoche M, Harding G. Eur J Clin Microbiol Infect Dis. 1998;17:542-550.
S. anginosus
64
©Copyright 2005 gbf.de / All rights reserved
B. fragilisE. coli
S. epidermidis
©Copyright 2005 cmsp.com / All rights reserved©Copyright 2005 cmsp.com / All rights reserved
What empiric antibiotics would you choose at this time?
A. Ceftriaxone + metronidazole
B. Pipercillin/tazobactam
C. Imipenem
D. Tigecycline
E. Ciprofloxicin + metronidazole
Secondary Peritonitis(Antibiotic Selection)
Enterobacteriacea
Amoxicillin / clavulanate
Piperacillin / tazobactam
Carbapenems
3rd gen cephalosporins
4rd gen cephalosporins
Aztreonam
Fluoroquinolones
± aminoglycoside
Tigecycline
B. Fragilis Group
Metronidazole
Clindamycin
Amoxicillin / clavulanate
Piperacillin / tazobactam
Cefoxitin
Carbapenems
Moxifloxacin
Tigecycline
Enterococcus
Ampicillin
Vancomycin
Ticoplanin
Telavancin
±Aminoglycosides
Daptomycin
Linezolid
Qunupristin/Dalfopistin
Tigecycline
Risk factors for ESBL, AmpC or MDR?
CT Scan Report
• Significant wall thickening involving the large and small bowel loops with patent abdominal vessels, probably representing nonocclusive bowel ischemia with differential diagnosis inflammatory bowel disease.
• Interval progression of ascites with interval regression of pneumoperitoneum.
• Interval progression of bilateral pleural effusion with passive basal atelectatic changes. The rest of the examination is unchanged compared with the recent previous study done on 1 February 2010.
ICU Course
• Laporatomy revealed peritonitis
• No clear perforation site
• Washing and drains placed
• Improved over the next days
• Discharged to floor
February 19, 20010
• Fever: T: 101.3• Hypotension: SBP 70• Tachypnea: RR 32• Tachycardia: 130/min• WBC: 28.4
• pO2: 56 on FiO2 60%
• Thrombocytopenia: 87,000• Anuric• Lactic acid: 4.2
SepsisSIRS Severe Sepsis Septic ShockInfection
Chest 1992;101:1644
Sepsis Continuum
A clinical response arising from a nonspecific insult, with 2 of the following: T >38oC or
<36oC HR >90
beats/min RR >20/min WBC
>12,000/mm3 or <4,000/mm3 or >10% bands
Microorganism invading
sterile tissue
SIRS with a presumed
or confirmed infectious process
Sepsis with organ failure
Vascular collapseRenalHemostasisLungLA
Refractoryhypotension
Burns
Trauma
Sepsis Syndromes1992: SCCM/ACCP
Parasite
Virus
Fungus
BacteriaBSI
SevereSepsis
ShockSevereSIRS
Infection SIRSSepsis
What is the likely source of sepsis?
A. Line infection?
B. Nosocomial pneumonia?
C. Further cIAI with or without abscesses?
D. Urinary catheter-related infection?
E. C-diff colitis
F. Any of the above
Severe Sepsis Management
Source Control
Appropriate and Adequate Empiric
Antibiotics
Early Goal Directed Therapy
Which of the following organisms is least likely in this situation?
A. Bacteroides fragilis
B. Pseudomonas aerugniosa
C. Proteus mirabilis
D. Candida albicans
E. Enterococcus
CR-UTI(Antibiotic Selection)
Pseudomonas
Piperacillin / tazobactam
Carbapenems
Ceftazidime
Cefepime
Ceftobiprole
Aztreonam
Ciprofloxacin
± aminoglycoside
Candida
Ampho B
Azoles
Enterococcus
Ampicillin
Vancomycin
Ticoplanin
Telavancin
±Aminoglycosides
Daptomycin
Linezolid
Qunupristin/Dalfopistin
Tigecycline
Risk factors for ESBL, AmpC or MDR?
What empiric antibiotics would you choose at this time?
A. Ceftazidime
B. Pipercillin/tazobactam
C. Imipenem
D. Tigecycline
E. Ciprofloxicin
February 25, 2010
• Wound dehiscence
• Surgically reduced
• Complicated with intra-abdominal bleed which was surgically and medically controlled
March 1, 2010
• Distended abdomen
• Decreased bowel sounds
• Fever
• WBC 2.5
• Abdominal fluids: >1200 WBC, 85%PMN’s
Which of the following organisms is least likely in this situation?
A. Bacteroides fragilis
B. Pseudomonas aerugniosa
C. Proteus mirabilis
D. Candida albicans
E. Enterococcus
Which of the following resistant mechanism is likely in this situation?
A. ESBL
B. AmpC
C. KPC
D. Capabemases
E. Any of the above
What empiric antibiotics would you choose at this time?
A. Tigecycline + anidulafungin
B. Colistin + anidulafungin
C. Meropinem + anidulafungin
D. Colistin+ Ceftazidime + anidulafungin
E. Piperacillin/tazobactam + anidulafungin
Tertiary Peritonitis(Antibiotic Selection)
MDR Pseudomonas
Meropenem
Doripenem
Imipenm
Colistin
Cefepime
Ceftobiprole
Aztreonam
Ciprofloxacin
± aminoglycoside
Candida
Ampho B
Anidulafungin
Caspofungin
Micafungin
Fluconazole
Voriconazole
Enterococcus
Ampicillin
Vancomycin
Ticoplanin
Telavancin
±Aminoglycosides
Daptomycin
Linezolid
Qunupristin/Dalfopistin
Tigecycline
Risk factors for ESBL, AmpC or MDR?
Antibiotic Course
Pip/Taz
Vancomycin
Meroppenem
Vancomycin
Fluconazole
Pip/Taz
Vancomycin
Meropenem
Colistin
Caspofungin
Vancomycin
Antibiotic Course
Pip/Taz
Vancomycin
Meroppenem
Vancomycin
Fluconazole
Pip/Taz
Vancomycin
Meropenem
Colistin
Caspofungin
Amikacin
Tigecycline
Findings
Quite large amounts of pleural effusion seen on the right side with adjacent atelectasis and spread opacifications seen in the visualized lower part of the lung. The amount of pleural effusion on the right side is essentially unchanged compared to previous examination dated February 6, 2010. On the left side, the pleural effusion seen previously has resolved and there is now atelectasis seen in the lower part of the left lung.
No free air intraabdominally. Nasogastric tube with its tip in the duodenum. Double abdominal drains, one on each side. There are dilated bowel loops, both small and large bowel, but there is gas seen all the way to the rectum. There is some free fluid intraabdominally with variable attenuation. No certain collection though. The variability of the free fluid density is of uncertain cause, contrast leak? though no free air. Blood/clotted blood? Kidney transplants seen to the left and right in the pelvis. Splenomegaly. Previous examination revealed extensive wall thickening of both small and large bowel. Today, there is remaining wall thickness of small bowel loops.
What persistent pseudomonas bacteremia indicate?
A. Persistent intra-abdominal infection
B. Persistent pneumonia
C. Catheter related blood stream infection
D. Enterovesicular fistula
E. Endocarditis
What antibiotics would you add?
A. Bactrim
B. Doxyclycline
C. Tigecycline
D. Imipenem
E. Chramphenicole
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