Pyrexia - PACT - ESICM

Task 2. Determining the cause of fever in the critically ill patient
tracheal tube for mechanical ventilation and his sputum had become
purulent. Interpret the CXRs and give your presumptive diagnosis.
Day 1 Day 3
A. The chest radiograph two days later (right), shows the development of a pleural
effusion. Taking the radiological infiltrates together with the clinical signs (purulent
secretions, gas-exchange deterioration and fever), there is presumptive evidence of
ventilator-associated pneumonia.
Q. How would you prove a diagnosis of VAP
A. Microbiological proof may be obtained by a positive culture from sputum or distal
bronchial sample (see microbial diagnostic criteria above) or from the pleural fluid. In
this instance, the cultures of tracheal aspirate and pleural fluid yielded Serratia
marcescens which was subsequently successfully treated by ceftriaxone.
Central venous catheter-related infections
Catheter infection should be suspected in the febrile ICU patient with an
intravascular catheter when
There is fever or a positive blood culture in the absence of another
evident source of infection
The CVC dwell time exceeds 3 days
Fever abates after catheter removal
There are signs of local (exit-site) infection.
Signs of exit-site infection include redness and purulent discharge.
The definitive diagnosis of central venous catheter-related infection is normally
made after CVC removal and demonstration of a positive catheter tip culture
with an identical micro-organism grown from a percutaneous ‘clean-stick’
culture(s), drawn peripherally and simultaneously, from blood.
Some important definitions
Exit-site catheter infection is defined as the presence of positive quantitative
catheter culture in the presence of symptoms of local infection (erythema,
tenderness, induration, or purulence), in the absence of other foci.
Catheter-related blood stream infection (CRBSI) is diagnosed when the same
organism is isolated (at higher concentrations – see below) on quantitative
culture of the distal catheter segment and from the blood of a patient with
[18]