Pyrexia - PACT - ESICM

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Task 1. Assessing and measuring fever in ICU Blood should be obtained percutaneously via venipuncture (or via ‘clean-stick’, newly introduced arterial or central venous catheters), and 10 ml placed in each of two bottles for aerobic/anaerobic cultures. At least two to three sets, 10 min apart, should be taken, after proper skin preparation. Shafazand S, Weinacker AB. Blood cultures in the critical care unit: improving utilization and yield. Chest 2002; 122(5): 1727-1736. PMID 12426278 Microbiology The commonly identified micro-organisms causing infections in the ICU include Gram-negative bacilli (mainly Enterobacteriaceae, Klebsiella, Pseudomonas, Acinetobacter and Serratia spp.), Gram-positive bacteria such as coagulasenegative staphylococci and S. aureus and Candida albicans. Organisms should always be considered in the specific clinical context when making ‘best guess’ therapeutic decisions Blood culture results with S. epidermidis are considered clinically ‘significant’, if present in more than one bottle and are rapidly growing in culture. Candida spp. may cause catheter-related blood stream infections, wound infections, and peritonitis. Culture of Candida spp. may, of course, represent colonisation as opposed to infection, but there are no commonly accepted criteria to separate these conditions. Candiduria exceeding 10 5 colony forming units/mL in two urine specimens taken before and after change of a bladder catheter in a patient with clinical signs of sepsis may point to Candida as the aetiology. A high Candida colony count in urine, recovery from two or more otherwise sterile sites (excluding urine and sputum) may point to Candida sepsis in the febrile ICU patient with leukocytosis (>12.0 x 10 9 /L). Candidaemia (e.g. after change of intravascular catheters) is indicative of infection. Candida endophthalmitis, oesophagitis, suppurative thrombophlebitis or wound infections/peritonitis (‘open abdomen’) may be the source of deep Candida infections. Further relevant details are to be found in the following reference. Holley A, Dulhunty J, Blot S, Lipman J, Lobo S, Dancer C, et al. Temporal trends, risk factors and outcomes in albicans and non-albicans candidaemia: an international epidemiological study in four multidisciplinary intensive care units. Int J Antimicrob Agents 2009; 33(6): 554. e1-7. Epub 2009 Jan 22. PMID 19167196 Viral infections causing pneumonia, even in critically ill, immunocompromised (or immunocompetent) patients, are rare. Herpes virus, cytomegalo, adeno- or respiratory syncytial viruses or Chlamydia spp. are considered the most frequent causes. [10]
Task 1. Assessing and measuring fever in ICU Jaber S, Chanques G, Borry J, Souche B, Verdier R, Perrigault PF, et al. Cytomegalovirus infection in critically ill patients: associated factors and consequences. Chest 2005; 127(1): 233–241. PMID 15653989 Limaye AP, Kirby KA, Rubenfeld GD, Leisenring WM, Bulger EM, Neff MJ, et al. Cytomegalovirus reactivation in critically ill immunocompetent patients. JAMA 2008; 300(4): 413–422. PMID 18647984 Chiche L, Forel JM, Roch A, Guervilly C, Pauly V, Allardet-Servent J, et al. Active cytomegalovirus infection is common in mechanically ventilated medical intensive care unit patients. Crit Care Med 2009; 37(6): 1850–1857. PMID 19384219 THINK about the common clinical contexts relevant to these specific organisms. When do you think viral reactivation is harmful and when not Q. Why is viral reactivation important in clinical management A. In order to make an informed decision as to appropriate ‘best guess’ antibiotic treatment. Rare fungal infections developing in the critically ill may include Aspergillus fumigatus lung infections after near drowning or in the neutropenic/organ transplant patient with underlying haematologic malignancy or immunosuppression. A rare cause of bilateral sinusitis may be infection with Rhizopus (mucormycosis), particularly in diabetics, as illustrated in the references below. Gans RO, Strack van Schijndel RJ, Laarman DA, Stilma JS, Thijs LG. Fatal rhinocerebral mucormycosis and diabetic ketoacidosis. Neth J Med 1989; 34(1-2): 29–34. PMID 2492643 Dimopoulos G, Vincent JL. Candida and Aspergillus infections in critically ill patients. Clin Intens Care 2002; 13: 1–12 Fishman JA. Infection in solid-organ transplant recipients. N Engl J Med 2007; 357(25): 2601–2614. PMID 18094380 For further insight into the evolution of microbiology of nosocomial bacteraemia in the ICU, see: Edgeworth JD, Treacher DF, Eykyn SJ. A 25-year study of nosocomial bacteremia in an adult intensive care unit. Crit Care Med 1999; 27(8): 1421–1428. PMID 10470744 [11]
Page 1 and 2: AN ESICM MULTIDISCIPLINARY DISTANCE
Page 3 and 4: LEARNING OBJECTIVES After studying
Page 5 and 6: Introduction INTRODUCTION Thirty pe
Page 7 and 8: Task 1. Assessing and measuring fev
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Page 19 and 20: Task 2. Determining the cause of fe
Page 35 and 36: Task 3. Fever in specific categorie
Page 39 and 40: Fever in neurological disease Task
Page 43 and 44: Task 4. Understanding and treating
Page 51 and 52: Self-assessment EDIC-style Type A 8
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Page 55 and 56: Patient Challenges Q. Outline the p
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Page 61 and 62: syndrome was clear and antibiotics,
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Patient Challenges often a transien
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Pyrexia - PACT - ESICM

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