antibiotic use in the icu

Fever in the ICU Patient... • Complicated wound infection• Bacteremia of uncertain source... Antibiotics • Drugs chosen based on potential pathogens present • Rotate common, empiric ant

Antibiotic Use in the ICU

Fever in the ICU Patient

Fever

• Complicated wound infection

• Bacteremia of uncertain source

Antibiotics

• Drugs chosen based on potential

pathogens present

• Rotate common, empiric antibiotics

every couple of months

Community-Acquired

Community-Acquired

Community-Acquired

Community-Acquired

Community-Acquired

• Risk factors for Pseudomonas

– Structural lung disease – Corticosteroid therapy

• > 10 mg prednisone/day

– Use of broad-spectrum antibiotics

• > 7 days in past month

– Malnutrition

Hospital-Acquired: Severe pneumonia

• Admission to ICU

• Severe respiratory failure

– Need for mechanical ventilation – PaO 2 /FIO 2 < 250 mmHg

• CXR

– Bilateral involvement – Multilobar involvement

Hospital-Acquired: Severe pneumonia

• Shock

– Hypotension – Need for vasopressors

• Acute renal failure

– Requiring dialysis – Oliguria

• < 20 mL/hr

• < 80 mL/4 hrs

Hospital-Acquired

Hospital-Acquired

Hospital-Acquired

Sinusitis

ICU

• 85% incidence with nasotracheal ETT

• Pathogens similar to nosocomial

ICU

• No criteria developed to differentiate UTI

from asymptomatic bacteruria

• 30% colonization rate with foley

– < 3% develop bacteremia

• UTI unlikely to cause high fevers/sepsis

– Error on the side of treating

Empiric Treatment

• 3rd cephalosporin

– cefotaxime or ceftriaxone – Avoid ceftazidime

• Less Gram (+) activity

• Steroids

– S pneumoniae & H flu

C Difficile

Clinical Presentations

• Diarrhea without colitis

– Most common – Mild diarrhea, +/- abdominal cramps – +/- mild abdominal tenderness, fever,

leukocytosis

– Usually stops with discontinuation of

antibiotics

C Difficile

Clinical Presentations

• Colitis without pseudomembranes

– More serious illness – Malaise, abdominal pain , anorexia, moderate to severe diarrhea

– Low grade fever, dehydration, lower

abdominal tenderness, leukopcytosis

– More of a sepsis/septic shock picture

• Multiple organ involvement

• Fulminant colitis

C Difficile

Treatment

• Severe cases/unable to take po

– Metronidazole (+/- oral vancomycin)

• (500 mg IV q8)

• Indications for surgery (1% - 3%)

– Peritonitis – Bacteremia unresponsive to antibiotics – Progressive disease despite antibiotics – CT scan of significant colonic wall edema

Intra-Abdominal Infection

Empiric Treatment

• Community-acquired

– Cefotetan/cefoxitin – Metronidazole/clindamycin + Gram (-)