Download Detection and Management of Fever and Infection in the

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