Life-Threatening Infections

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 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

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 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

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 SCCM / ACCP Consensus
Conference Definitions
• Infection
• Systemic inflammatory response
syndrome (SIRS)
• Sepsis
• Severe sepsis
• Septic shock

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 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

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 Principles of Diagnosis
• Epidemiologic setting
– Community
– Modified community
– Hospital
• Predisposing conditions
– Extremes of age
– Immunocompromise
– Prosthetic devices
– Invasive procedures
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 Systemic Manifestations
of Infection
• Fever (or normo-/hypothermia)
• Chills
• Tachypnea/dyspnea
• Nausea/vomiting
• Tachycardia
• Hypotension
• Hypoperfusion
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 Site-Specific Manifestations
of Infection
• Central nervous system
• Respiratory tract
• Abdomen
• Urinary tract
• Skin/wound

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 Laboratory Evaluation

• White blood cell count

• Coagulation abnormalities
• Glucose metabolism
• Acid-base status
• Renal function
• Hepatic function

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 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

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

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 Meningitis
• Community-acquired
– Streptococcus pneumoniae
– Neisseria meningitidis
• Immunocompromise, neurosurgery,
hospital-acquired
– Staphylococcus aureus
– Listeria
– Gram-negative bacteria

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 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

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

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 Community-Acquired Pneumonia
(Immunocompetent)
• Organisms
– S. pneumoniae,
H. influenzae
• Antibiotics
– Macrolide + second-/third-
generation cephalosporin
– Ampicillin/sulbactam
– Legionella coverage
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 Community-Acquired Pneumonia
(Immunocompromised)
• Pneumocystis carinii
– Trimethoprim/sulfamethoxazole
– Pentamidine
– Consider steroids if hypoxemic
• Fungal
– Amphotericin B

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

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

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 Urinary Tract Infections
• Third-generation
cephalosporin
• Quinolone
• Trimethoprim/
sulfamethoxazole
• Aztreonam
• Consider complications
• Candiduria

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 Cutaneous Infections
• Organisms – S. aureus, b-hemolytic
streptococci, H. influenzae, C. perfringens
• Antibiotics
– Cefazolin
– Nafcillin
– Vancomycin
– Penicillin G (C. perfringens and b-
hemolytic streptococci)
• Wound toxic shock
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 Necrotizing Fasciitis
• Immediate surgical consult for
debridement
• Polymicrobial infection
• Antibiotics
– Ampicillin/sulbactam
– Ticarcillin/clavulanate
– Piperacillin + aminoglycoside
+ clindamycin
– Imipenem
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 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
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 Immunocompromised or
Neutropenic Patients
• Third- or fourth-generation cephalosporin
+ aminoglycoside
• Imipenem or meropenem
• Ticarcillin/clavulanate
• Piperacillin/tazobactam
• Vancomycin if gram-positive organisms
likely
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 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
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 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
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 Serious Infections in Infants
and Children
• Meningitis
• Epiglottitis
• Bacterial tracheitis
• Retropharyngeal abscess
• Croup

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 Key Points

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