Fever - cgmh.org.tw hour_Inf.pdf · •Definitions •Principles to approach fever or infection •Introduction of antibiotics •Prophylaxis •Culture report Contents •

Fever

• Definitions

• Principles to approach fever or infection

• Introduction of antibiotics

• Prophylaxis

Contents

• Definitions

• Principles to approach fever or infection

• Introduction of antibiotics

• Prophylaxis

• Culture report

Contents

• Controlled by hypothalamus

• Core body temperature: 36.5℃~ 37.5 ℃

• 體溫最低時間：早上6點體溫最高時間：下午4～6點

• Oral temperature: 36.8 ℃ ± 0.4 ℃Rectal temperature: 比口溫高0.4 ℃耳溫約接近肛溫

Body temperature

• Definition: AM > 37.2 ℃ or PM > 37.7 ℃

• An increase in the hypothalamic set points

• Hyperpyrexia (高熱): > 41.5 ℃

– CNS related (ex: CNS hemorrhage)

– Severe infection

Fever

Fever

• 下視丘設定不變，但產熱 > 散熱

Hyperthermia

• Systemic inflammatory response syndrome

→ 兩項以上符合：

– Fever (oral >38°C) or hypothermia (<36°C)

– Tachypnea: >20 breaths/min or

PaCO2<32mmHg

– Tachycardia: >90 beats/min

– WBC > 12000 or <4000, or >10% bands

• Sepsis = SIRS + proven/suspected microbial

etiology

SIRS & sepsis

Infectious diseases

JAMA. 2016;315(8):801-810.

• Sepsis + tissue hypoperfusion or organ

dysfunction

Severe sepsis

• Definitions

• Principles to approach fever or infection

• Introduction of antibiotics

• Prophylaxis

• Culture report

Contents

• History: TOCC and clinical symptoms

– Infection? Or fever with other causes

– Bacterial infection?

• The location of infection

• Community or hospital / healthcare

• Previous culture?

• Clinical condition: critical? Septic shock?

For new patients……

Community or hospital

• Pneumonia

– CURB-65

– Clinical Pulmonary Infection Score (CPIS)

(> 6, suggestive of pneumonia)

• Infective endocarditis: Duke’s criteria

• Fungal infection: Candida score

Scorings or Criteria

• 重新評估病人可能發燒的原因→ History

taking + PE

• 最近的Blood culture或各種culture

→ 如果太久，應評估是否重新收culture

• 相關檢查：CXR、Urine routine、抽血等

• 評估是否給Antibiotics

• 症狀緩解

When you are on duty…

• Check cultures!

• Evaluate the clinical condition after 3 days

– Symptoms and signs

– Lab data: WBC, CRP, procalcitonin

(Do NOT recheck procalcitonin regularly)

– Recheck scorings (ex: CPIS)

– Ensure the culture data!

• The fewer antibiotics, the better!

When you start to use Abx,

Abx vs. blood-brain barrier

• Adjust renal dose in IV form, except:

– Renal/biliary: ceftriaxone

– Biliary: tigecycline, metronidzone

– Metabolism: linezolid, moxifloxacin

• Monitor kidney and liver function

– Aminoglycosides, vancomycin

– Rifampin

Kidney and Liver

• Direct:

– GI disturbance, allergy, drug fever, etc.

– nephrotoxicity + ototoxicity (aminoglycosides), neurotoxicoty, cardiac toxicity (macrolides), bone marrow suppresion (linezolid)

– drug-drug interaction

• Indirect:

– change flora

– drug-resistant pathogens

Side effects

• According to clinical conditions and the

results of cultures!

• Empiric → definitive (narrow)

• IV form → oral form, except

– Infective endocarditis

– CNS infection

De-escalation of antibiotics

• Recheck the infection source and culture

• Clearing the source is better than only

antibiotics use!

If becoming worse, ……

• Acetaminophen

• Aspirin

• Nonsteroidal anti-inflammatory drugs

(NSAIDs): PGE2 inhibitors

• Glucocorticoids

• Paroxysmal sympathetic hyperactivity:

Morphine, beta-blockers, BZDs, etc.

Antipyretics

• Acetaminophen: impaired liver function if

4g/day (一天不超過八顆)

• Aspirin: Reye’s syndrome in children

• NSAIDs: GI bleeding, acute kidney injury,

poor-controlled hypertension

• Glucocorticoids: Immunosuppressive

Antipyretics: side effects

• 冰枕、水浴擦拭等物理性降溫

• IV fluid

• 避免酒精擦拭：退溫太快，可能導致失溫

如果藥物沒有效

• Definitions

• Principles to approach fever or infection

• Introduction of antibiotics

• Prophylaxis

• Culture report

Contents

Antibiotics

• Bactericidal drugs:

– death and disruption of the bacterial cell

• Bacteriostatic drugs:

– inhibit bacterial replication without killing

– rely on an intact immune system

– inhibits protein sunthesis

– Aminoglycosides, Macrolide, Tigecycline,

Linezolid

Bactericidal vs. Bacteriostatic

Pharmacodynamic properties

Pharmacodynamic properties

Parameter predicting

responseDrug or drug class

Time above the MIC Beta-lactams, aztreonam

24-h AUC/MIC

Aminoglycosides, fluoroquinolones,

macrolides, tigecycline, daptomycin,

vancomycin, etc.

Peak to MIC Aminoglycosides, fluoroquinolones

• Definitions

• Principles to approach fever or infection

• Introduction of antibiotics

• Prophylaxis

• Culture report

Contents

• Use Amoxicillin

• Patients who need antibiotics prophylaxis

– Prosthetic valves

– History of infective endocarditis

– Congenital cyanotic heart disease without

repair or residual defect after repair

Infective endocarditis

Surgical - NNIS

Surgical

• Definitions

• Principles to approach fever or infection

• Introduction of antibiotics

• Prophylaxis

• Culture report

Contents

37

38

Blood culture

Staphylococcus-like: S.aureus, CoNS ...

Streptococcus-like: Streptococcus, Enterococcus ...

GNB

39

Blood culture

40

Urine culture

41

Wound culture

Tissue culture during operation is more specific

Anaerobic culture?

Thanks for your listening

Any Q?

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