Infection in ICU: Infection in ICU: LRTI, UTI, Blood Stream, Skin, & GIT LRTI, UTI, Blood Stream, Skin, & GIT Iman Galal, MD Iman Galal, MD Ass. Professor of Pulmonary Medicine/Ain Shams Ass. Professor of Pulmonary Medicine/Ain Shams University University E-mail: [email protected]E-mail: [email protected]
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Infection in ICU:Infection in ICU:LRTI, UTI, Blood Stream, Skin, & GITLRTI, UTI, Blood Stream, Skin, & GIT
Iman Galal, MDIman Galal, MDAss. Professor of Pulmonary Medicine/Ain Shams UniversityAss. Professor of Pulmonary Medicine/Ain Shams University
Quantitative blood culture:Quantitative blood culture:CRBSI is suggested when the number of microbes from a CVC sample of blood is 5 times that from a simultaneously collected peripheral sample. This is not widely available.
Acridine orange staining of blood taken from the CVC: Acridine orange staining of blood taken from the CVC: Not widely available.
Endoluminal brush sampling:Endoluminal brush sampling:A tiny brush is passed down the catheter lumen & is examined microbiologically by culture.This test has a high sensitivity & specificity but is not widely available.There are concerns about the generation of a bacteraemia caused by organisms dislodgement.
Differential time to positivity:Differential time to positivity:CRBSI is suggested when blood from CVC demonstrates microbial growth at least 2 h earlier than growth is detected in blood collected simultaneously from a peripheral vein.Most currently used automated blood culture systems can readily provide this information.
Selection of catheter typeSelection of catheter typeUse a single-lumen catheter unless multiple ports are essentialFor total parenteral nutrition, a dedicated CVC or lumen should be used exclusivelyConsider the use of an antimicrobial impregnated catheter for patients at high risk of CRBSISelection of catheter insertion siteSelection of catheter insertion siteBalance risks of infection against mechanical risks of insertionUse the subclavian route unless contraindicatedConsider the use of peripherally inserted catheters as an alternative to CVCsAseptic technique during insertionAseptic technique during insertionUse optimum insertion technique including sterile gown, gloves and drapesClean the insertion site with alcoholic chlorhexidene gluconate solution (or alcoholic povidone iodine) and allow to dryCatheter & catheter site careCatheter & catheter site careBefore accessing the CVC, disinfect the external surfaces of the catheter hub and connection ports with an aqueous solution of chlorhexidene gluconate or povidone iodine (unless against manufacturer’s recommendations)Use sterile gauze or transparent dressing over the insertion siteCatheter flush solutions should contain anticoagulantReplacement strategiesReplacement strategiesGuidewire exchange is acceptable for malfunctioning catheters if there is no evidence of infection
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Blood stream infections:TreatmentTreatment
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► Remove the catheter if CRBSI is suspected.
► If the line is ‘precious’ and/or other access impossible, it may be justifiable to leave the catheter in place & treat medically.
► Some clinicians practice guidewire exchange for ‘precious’ catheters.
► If the removed catheter is proven on microbiological examination to be the source of sepsis then the exchanged catheter is removed & another site selected.
► Antibiotic therapy should be based on culture reports.
► One week’s treatment may be appropriate where the catheter has been removed, 2 weeks if the infection is caused by Staphylococcus aureus or fungi.
► Where deep-seated infection is suspected, further imaging and prolonged antibiotic therapy may be required.
► If microbiological data are not available or treatment is indicated before cultures are complete, blind antibiotic therapy should target the likely pathogens (including resistant Gram-negative organisms and methicillin-resistant S. aureus)
pneumonia (VAP), subclassifications of nosocomial pneumonia, are
considered to be the most serious hospital-acquired infections
because of their relatively high associated morbidity & mortality.
► HAP is defined as pneumonia that occurs 48 h after hospital admission
that did not appear to be incubating at the time of admission.
► VAP is pneumonia that arises > 48–72 hrs after endotracheal
intubation.
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HAP & VAP: Risk Factors for MDR PathogensRisk Factors for MDR Pathogens
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► Antimicrobial therapy in preceding 90 d
► Current hospitalization of 5 d or more
► High frequency of antibiotic resistance in the ICU
► Immunosuppressive disease and/or therapy
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HAP & VAP: Recommendations for diagnosisRecommendations for diagnosis
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► New or progressive pulmonary infiltrate & 2 of fever, leukocytosis, or sputum purulence is most accurate clinical criteriaclinical criteria
► Perform blood cultures
► Cultures for LRT secretions before initiating antimicrobial therapy
► Negative culture result of appropriate LRT specimen in absence of change in antimicrobial therapy in preceding 72 h virtually rules out pyogenic bacterial infection (exception includes Legionella)
► Reliable tracheal aspirate Gram stain can be used to direct initial antimicrobial therapy & may increase the diagnostic value of CPIS
► Quantitative cultures can be performed on endotracheal bronchoscopically or non-bronchoscopically samples
► Modified CPIS of 6 for 3 days is a criterion to select patients at low risk for early discontinuation of empirical therapy of HAP
American Thoracic Society and Infectious Disease Society of America
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HAP & VAP:Duration of Antimicrobial TreatmentDuration of Antimicrobial Treatment
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► As short as 7 days, provided that the etiologic pathogen is not
Pseudomonas aeruginosa and that the patient has a good clinical
response
American Thoracic Society and Infectious Disease Society of America
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HAP & VAP: Assessment of Non-respondersAssessment of Non-responders
04/07/23
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Nosocomial Gastrointestinal Tract Infection:
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Term Definition
Gastroenteritis A syndrome characterized by gastrointestinal symptoms including nausea, diarrhea, and abdominal discomfort
DiarrheaAbnormal fecal discharge characterized by frequent and/or fluid stool; usually resulting from disease of the small intestine and involving increased fluid and electrolyte loss
DysenteryAn inflammatory disorder of the GIT often associated with blood and pus in the feces and accompanied by symptoms of pain, fever, abdominal cramps; usually resulting from disease of the large intestine
Enterocolitis Inflammation involving the mucosa of both the small and large intestine
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► Shigella: 101-2
► Giardia lamblia: 101-2
► Entamoeba histolytica: 101-2
► Campylobacter jejuni:102-6
► Salmonella: 105
► E. coli: 108
► Vibrio cholerae: 108
Nosocomial GIT: Infectious doses of enteric pathogensInfectious doses of enteric pathogens