Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Detection and Management of Fever and Infection in the CICU John T. Berger, MD Medical Director, Cardiac Intensive Care Disclosures • None Financial • I am not an expert in infectious disease • The only infection I know anything about is critical pertussis 48,277 Cases 4994 < 1 year 20 deaths 16 < 1 year Pulmonary Hypertension in Pertussis PH seen in 75% of patient who died Leukoreduction in Critical Pertussis • 14 Patients (11%) – Exchange transfusion (12), leukopheresis (1), both (1) – 8 had pulmonary hypertension detected – 4 had treatment on study day 0 • No apparent survival benefit Patients with WBC Count > 50K by leukoreduction status Total Survivors Leukoreduction 13 8 No Leukoreduction 12 9 Objectives • Outline the diagnostic dilemmas of nosocomial infection and fever • Discuss the rise and fall of procalcitonin as biomarker for infection Fever in the ICU • Fever Prevalence 26-70% – Etiology equally split between infectious and noninfectious etiologies • Prolonged fever more likely to be infection • Fever a/w increased length of stay and possibly mortality • 737 Adult ICU Patients – In septic patients, NSAIDS/Acetaminophen a/w increased mortality (2-2.5 odds ratio) versus non-septic patients with reduced mortality risk (OR 0.22-0.58) Lee et al. Crit Care 2012, 16:R33 Fever in the PICU • PICU – Netherlands – 202 Children – 40% with fever during ICU stay • Only ½ with infection – Most within 48 hours of admission – Associated with increased PICU length of stay and mechanical ventilation • Gordjin et al. J Int Care Med 2009 Fever ≠ Infection • 3 mon old s/p TOF repair. Temp 38.8 C, WBC 15,000; CXR unchanged • How many would send cultures on day 1 before exam? – Blood, Urine, Tracheal Aspirate • 66 post op febrile patients with blood cultures in 1st 48 hours – 1 positive culture (staph epid) • Kiragu PCCM 2009 10:364 • What about day 4? • Fever “merits clinical assessment by a healthcare professional… prior to any laboratory tests or imaging procedures” – Am College of Crit Care Med 2008 Infectious Sources of Fever Noninfectious • •• •• Meningitis Otitis Media CLA-BSI Sinusitis Endocarditis • • • •• • • • • Ventilator NEC associated • • Drugs • CAUTI LRTI • • Transfusion Reactions • Pyelonephritis PICC or Site Surgical • • Endocrine Disorders • Perineal Femoral BSI Infectionor (Adrenal insufficiency, • perirectal abscess Cellulitis thyrotoxicosis) Arthritis • Malignancy Pressure Ulcer • Inflammatory disorders • •• •• Brain Injury Seizures Infarction CVA Pulm Embolus ARDS Pancreatitis Pericarditis Acalculous Heart Failure DVT cholecystitis Drug Eruptions Ischemic colitis Environment, Low cardiac output, & hyperthermia Wyndham. Ann NY Acad Sci, 1977 Fever and Infection • Adult Canadian (Calgary) ICUs – 18,989 admissions – Incidence of Fever fell from 50% to 25% – No change in BSI rate, Abx consumption • Niven et. al. CCM 2013, 41:1863 • CICU at CNMC – 1 CLABSI and 1 CAUTI in last year – Still lots of antibiotic use Infection Related Ventilator Associated Complications (IVACS) (A name only the CDC could love) • Most commonly diagnosed nosocomial infection in PICU • Incidence varies 0.3-45.1 / 1000 vent days • Accounts for ½ antibiotic use in PICU • Criteria for diagnosis neither sensitive or specific • CDC: Infection a/w increase in vent settings (PEEP by 2 cm H20 or Fio2 by 0.2) Would you send a tracheal aspirate? Start Antibiotics? 1. 4 mo old with RSV intubated for 3 days. New 38.5 C fever, WBC =14,000, but no change on CXR 2. 7 yo old intubated for 6 days for ARDS / near drowning. New fever (38.9), WBC = 13,000 and no CXR changes Tracheal Aspirates for IVAC • Survey of 118 MDs in PALISI (98% Attending) • 65% -obtained tracheal aspirates as part of a standard r/o sepsis work up – 42% without a standard collection method • “The RN or RT just does it” Wilson PCCM 2014; 15:715 IVAC Treatment Percentage who would prescribe Antibiotics RSV ARDS Gram Stain –Few PMN, Few GPC 2+MSSA, 2+PMN 34% 63% 79% 81% 2+MRSA, 2+PMN 81% 91% 2+ Pseudomonas, 2+PMN 80% 87% Wilson PCCM 2014; 15:715 Tracheal Aspirates • 335 samples from 61 intubated PICU patients without regard for clinical status – Predicted to be intubated for > 48 hours – 42% post op CV surgery or cardiomyopathy – None immunocompromised • Culture results not provided to clinical team • CDC Definition – > 104 cfu/ml = positive Cx – > 25 PMN / lpf Willson et. al. PCCM 2014; 15:299 TA do not discriminate between colonization and infection In Line Suction 90% % Patients with > 25 PMN/lpf Single catheter 40% Willson et. al. PCCM 2014; 15:299 40-90% Positive Cultures • CDC Clinical Criteria did not correlate with positive cultures – Fever, WBCs, Increase Secretions, Worse oxygenation, CXR changes • Typical Pathogens isolated – Staph A, Stenotrophamonas, Neisseria, Klebsiella, and Staph E – 80% of cultures Willson et. al. PCCM 2014; 15:299 What to do? Procalcitonin • Precursor protein of Calcitonin • Usually undetectable in healthy humans • Rises quickly in response to bacterial infection (IL-6, TNF-α) and less response in viral infection • Initial studies suggested as method to guide diagnose infection • Suggestions that it is better discriminator than CRP Procalcitonin in PICU • Single center study • 64 of 225 eligible children with SIRS (25 with bacterial infection) • PCT and CRP drawn when found to have SIRS • Infection adjudicated by blinded investigators • Compared CRP to PCT • 2.5 ng/ml PCT threshold Simon PCCM 2008 Procalcitonin Variability • High Inter-patient variability • Increases seen with cardiopulmonary bypass and other inflammatory states • Use shifted to guide abx therapy Schuetz et al. Curr Opin CCM 2013 Procalcitonin after Cardiac Surgery • 53 patients –All > 3 months, None Infected • All significantly elevated for 3 days Michalik Card in the Young 2006 Conclusions • Fever common problem • Diagnosis of infectious etiologies not as straightforward as waiting for culture results • Antibiotic stewardship and rational discontinuation remain important awaiting the application of new biomarker strategies