1. INF 1 ® Life-Threatening Infections INF 1 ®

2. INF 2 ® Objectives Recognize predisposing conditions for infection Identify clinical manifestations of infection Understand the use of the laboratory evaluation in suspected infection Outline principles for empiric antibiotic therapy List antimicrobial strategies for specific infections Recognize predisposing conditions for infection Identify clinical manifestations of infection Understand the use of the laboratory evaluation in suspected infection Outline principles for empiric antibiotic therapy List antimicrobial strategies for specific infections INF 2 ®

3. INF 3 ® Infection / Inflammation Principles Infection is a cause, comorbidity, and/or consequence of critical illness or injury Systemic response may produce or compound effects of other injury or illness Infection is a cause, comorbidity, and/or consequence of critical illness or injury Systemic response may produce or compound effects of other injury or illness

4. INF 4 ® SCCM / ACCP Consensus Conference Definitions Infection Systemic inflammatory response syndrome (SIRS) Sepsis Severe sepsis Septic shock Infection Systemic inflammatory response syndrome (SIRS) Sepsis Severe sepsis Septic shock

5. INF 5 ® Principles of Diagnosis Assessment of risk factors Systemic and site-specific signs and symptoms Laboratory data Additional studies – focused by signs, symptoms and supportive data Assessment of risk factors Systemic and site-specific signs and symptoms Laboratory data Additional studies – focused by signs, symptoms and supportive data

6. INF 6 ® Principles of Diagnosis Epidemiologic setting –Community –Modified community –Hospital Predisposing conditions –Extremes of age –Immunocompromise –Prosthetic devices –Invasive procedures Epidemiologic setting –Community –Modified community –Hospital Predisposing conditions –Extremes of age –Immunocompromise –Prosthetic devices –Invasive procedures

7. INF 7 ® Systemic Manifestations of Infection Fever (or normo-/hypothermia) Chills Tachypnea/dyspnea Nausea/vomiting Tachycardia Hypotension Hypoperfusion Fever (or normo-/hypothermia) Chills Tachypnea/dyspnea Nausea/vomiting Tachycardia Hypotension Hypoperfusion

8. INF 8 ® Site-Specific Manifestations of Infection Central nervous system Respiratory tract Abdomen Urinary tract Skin/wound Central nervous system Respiratory tract Abdomen Urinary tract Skin/wound

9. INF 9 ® Laboratory Evaluation White blood cell count Coagulation abnormalities Glucose metabolism Acid-base status Renal function Hepatic function White blood cell count Coagulation abnormalities Glucose metabolism Acid-base status Renal function Hepatic function

10. INF 10 ® Microbiological Studies Gram’s and other special stains Cultures before antibiotics Blood cultures( 2 sets with 10-15 ml) Sputum/tracheal secretions Semiquantitative urine culture Catheter exit site/intradermal segment Gram’s and other special stains Cultures before antibiotics Blood cultures( 2 sets with 10-15 ml) Sputum/tracheal secretions Semiquantitative urine culture Catheter exit site/intradermal segment

11. INF 11 ® Other Studies Chest –Radiograph –Thoracentesis Central nervous system –Lumbar puncture –CT or MRI Abdomen/retroperitoneum –Radiograph for free air –CT or ultrasound Chest –Radiograph –Thoracentesis Central nervous system –Lumbar puncture –CT or MRI Abdomen/retroperitoneum –Radiograph for free air –CT or ultrasound

12. INF 12 ® Principles of Antibiotic Selection Suspected pathogen(s) and site Gram ‘s stain or culture results, if available Assessment for antimicrobial resistance Comorbid conditions Parenteral administration in critically ill Suspected pathogen(s) and site Gram ‘s stain or culture results, if available Assessment for antimicrobial resistance Comorbid conditions Parenteral administration in critically ill

13. INF 13 ® Meningitis Community-acquired –Streptococcus pneumoniae –Neisseria meningitidis Immunocompromise, neurosurgery, hospital-acquired –Staphylococcus aureus –Listeria –Gram-negative bacteria Community-acquired –Streptococcus pneumoniae –Neisseria meningitidis Immunocompromise, neurosurgery, hospital-acquired –Staphylococcus aureus –Listeria –Gram-negative bacteria

14. INF 14 ® Antibiotics for Meningitis Ceftriaxone or cefotaxime High dose penicillin G – N. meningitidis Ampicillin or trimethoprim/sulfamethoxazole – Listeria Nafcillin, oxacillin or vancomycin – Staphylococcus Third-generation cephalosporin – gram negative bacilli Ceftriaxone or cefotaxime High dose penicillin G – N. meningitidis Ampicillin or trimethoprim/sulfamethoxazole – Listeria Nafcillin, oxacillin or vancomycin – Staphylococcus Third-generation cephalosporin – gram negative bacilli

15. INF 15 ® Other CNS Infections Encephalitis –Herpes simplex – acyclovir Brain abscess –Polymicrobial –Penicillin, metronidazole, and third- generation cephalosporin –Vancomycin if penicillin-allergic Encephalitis –Herpes simplex – acyclovir Brain abscess –Polymicrobial –Penicillin, metronidazole, and third- generation cephalosporin –Vancomycin if penicillin-allergic

16. INF 16 ® Community-Acquired Pneumonia (Immunocompetent) Organisms –S. pneumoniae, H. influenzae Antibiotics –Macrolide + second-/third- generation cephalosporin –Ampicillin/sulbactam –Legionella coverage Organisms –S. pneumoniae, H. influenzae Antibiotics –Macrolide + second-/third- generation cephalosporin –Ampicillin/sulbactam –Legionella coverage

17. INF 17 ® Community-Acquired Pneumonia (Immunocompromised) Pneumocystis carinii –Trimethoprim/sulfamethoxazole –Pentamidine –Consider steroids if hypoxemic Fungal –Amphotericin B Pneumocystis carinii –Trimethoprim/sulfamethoxazole –Pentamidine –Consider steroids if hypoxemic Fungal –Amphotericin B

18. INF 18 ® Nosocomial or Ventilator- Associated Pneumonia Aminoglycoside or fluoroquinolone + third- generation cephalosporin Ticarcillin/clavulanate or piperacillin/tazobactam Imipenem-cilastatin Two antipseudomonal agents Vancomycin for staphylococci –Linezolid or quinupristin-dalfopristin for resistance or intolerance Aminoglycoside or fluoroquinolone + third- generation cephalosporin Ticarcillin/clavulanate or piperacillin/tazobactam Imipenem-cilastatin Two antipseudomonal agents Vancomycin for staphylococci –Linezolid or quinupristin-dalfopristin for resistance or intolerance

19. INF 19 ® Abdominal Infections Surgical consultation Aerobic and anaerobic pathogens Monotherapy (if Pseudomonas unlikely) –Imipenem or meropenem –Piperacillin/tazobactam –Ticarcillin/clavulanate Surgical consultation Aerobic and anaerobic pathogens Monotherapy (if Pseudomonas unlikely) –Imipenem or meropenem –Piperacillin/tazobactam –Ticarcillin/clavulanate

20. INF 20 ® Abdominal Infections Combination therapy –Ampicillin + clindamycin + aztreonam –Ampicillin/sulbactam + aminoglycoside –Ticarcillin/clavulanate, imipenem, piperacillin/tazobactam + aminoglycoside –Cefoxitin or cefotetan + aminoglycoside –Quinolone + metronidazole or clindamycin Combination therapy –Ampicillin + clindamycin + aztreonam –Ampicillin/sulbactam + aminoglycoside –Ticarcillin/clavulanate, imipenem, piperacillin/tazobactam + aminoglycoside –Cefoxitin or cefotetan + aminoglycoside –Quinolone + metronidazole or clindamycin

21. INF 21 ® Urinary Tract Infections Third-generation cephalosporin Quinolone Trimethoprim/ sulfamethoxazole Aztreonam Consider complications Candiduria Third-generation cephalosporin Quinolone Trimethoprim/ sulfamethoxazole Aztreonam Consider complications Candiduria

22. INF 22 ® Cutaneous Infections Organisms – S. aureus,  -hemolytic streptococci, H. influenzae, C. perfringens Antibiotics –Cefazolin –Nafcillin –Vancomycin –Penicillin G (C. perfringens and  - hemolytic streptococci) Wound toxic shock Organisms – S. aureus,  -hemolytic streptococci, H. influenzae, C. perfringens Antibiotics –Cefazolin –Nafcillin –Vancomycin –Penicillin G (C. perfringens and  - hemolytic streptococci) Wound toxic shock

23. INF 23 ® Necrotizing Fasciitis Immediate surgical consult for debridement Polymicrobial infection Antibiotics –Ampicillin/sulbactam –Ticarcillin/clavulanate –Piperacillin + aminoglycoside + clindamycin –Imipenem Immediate surgical consult for debridement Polymicrobial infection Antibiotics –Ampicillin/sulbactam –Ticarcillin/clavulanate –Piperacillin + aminoglycoside + clindamycin –Imipenem

24. INF 24 ® Vascular Catheter Infections Remove catheter with systemic complications or exit site findings Coagulase-negative staphylococci –Catheter removal only– immunocompetent or no symptoms –Vancomycin – compromised or symptoms S. aureus – Oxacillin, vancomycin Gram-negative organisms – add aminoglycoside or third-generation cephalosporin Remove catheter with systemic complications or exit site findings Coagulase-negative staphylococci –Catheter removal only– immunocompetent or no symptoms –Vancomycin – compromised or symptoms S. aureus – Oxacillin, vancomycin Gram-negative organisms – add aminoglycoside or third-generation cephalosporin

25. INF 25 ® Immunocompromised or Neutropenic Patients Third- or fourth-generation cephalosporin + aminoglycoside Imipenem or meropenem Ticarcillin/clavulanate Piperacillin/tazobactam Vancomycin if gram-positive organisms likely Third- or fourth-generation cephalosporin + aminoglycoside Imipenem or meropenem Ticarcillin/clavulanate Piperacillin/tazobactam Vancomycin if gram-positive organisms likely

26. INF 26 ® Other Infections Antibiotic-associated colitis –Clostridium difficile infection –Discontinue implicated antibiotic –Oral regimen with metronidazole Fungal disease –Amphotericin B preferred –Fluconazole in less severely ill Antibiotic-associated colitis –Clostridium difficile infection –Discontinue implicated antibiotic –Oral regimen with metronidazole Fungal disease –Amphotericin B preferred –Fluconazole in less severely ill

27. INF 27 ® Pediatric Considerations – Meningitis Neonate: Group B streptococci, E. coli, L. monocytogenes, Enterococcus 2 months–2 yrs: S. pneumoniae, H. influenzae, N. meningitidis, Salmonella Treatment Ceftriaxone, cefotaxime Ampicillin (Listeria, Enterococcus) Consider dexamethasone Neonate: Group B streptococci, E. coli, L. monocytogenes, Enterococcus 2 months–2 yrs: S. pneumoniae, H. influenzae, N. meningitidis, Salmonella Treatment Ceftriaxone, cefotaxime Ampicillin (Listeria, Enterococcus) Consider dexamethasone

28. INF 28 ® Serious Infections in Infants and Children Meningitis Epiglottitis Bacterial tracheitis Retropharyngeal abscess Croup Meningitis Epiglottitis Bacterial tracheitis Retropharyngeal abscess Croup INF 28 ®

29. INF 29 ® Key Points