INFECTIOUS DISEASE
		PLAN Consider 1. No work-up necessary: Afebrile 2. Suspect New Infectious Etiology Fever work-up (see below) FEVER WORK-UP: Consider orgins of infection. Infection can occur from any site and spread to the blood. Examples: Hint: Where a tube sits, infection can occur. Blood: Central/Peripheral lines --------> bacteremia/sepsis Urinary Tract: Foley Catheter-------->urinary tract infection Lungs: Endotracheal tube ----->pneumonia Wound(surgical/trauma): Jackson pratt drains Other sites: GI Tract, skin (wound or bed sore), bone. Post surgical fever origins remembered by the " 5 Ws" Wind-atelectasis Water-urinary tract infection Wound-look for cellulitis, tenderness, purulence, fluctuance. Walking-pulmonary embolus Wonder drug-drug fevers DIAGNOSTICS If suspect Sepsis do the following: blood cultures x 2 urine anaylsis and culture and sensitivity Chest Xray (4 blood cultures if suspect endocarditis) Consider other studies. Examples:  Chest Xray  Computed Tomography  Echocardiogram TREATMENT Start/ continue/ change/ discontinue antibiotics based on results Starting Antibiotics: Empiric, Therapeutic, Prophylactic Therapeutic: Culture and Sensitivity back and shows growth of specific microbe. Sanford Guide to Antimicrobial Therapy helps choose best drug. Empiric: Started even if cultures are not back because risk of deterioration is too great without them. When to Give EMPIRIC therapy?  Clinical sepsis-fever, tachypnea, tachycardia in association with evidence of other organ system dyfunction. Septic shock will include low blood pressure. Fever in a neutropenic host  Probable Acute Localized Infection which may progress or cause significant organ damage before culture or other diagnostic studies are available.  Bacterial meningitis  ?Endocarditis?  Pneumonia-means documented change on chest xray study.  ?Pyelonephritis? When NOT to treat.  Fever alone in a stable or clinically improving patient.  Chronic illness, not likely of bacterial etiology.  When definitive diagnostic studies might be compromised by prior antibiotic use and risk of clinical deterioration is low. The surgical ICU at UCSD has put together some EMPIRIC GUIDELINES that have been revised 1/2001 and are unique to the SICU: Broad-spectrum: Sepsis Gram + coverage (Staph Aureus): CEFTRIAXONE/VANCOMYCIN (MRSA) Gram - coverage (Pseudomonas): CEFTAZADIME 1-2 g IV q 8 h Anaerobe (Clostridia, B. Fragilis): FLAGYL Hospital Acquired pneumonia: started > 72 hours after admission to the ICU/hospital. Gram + cocci only (Staph/Strep): CEFAZOLIN 1 gm IV q 8 h if allergic to above: VANCOMYCIN Gram - rods: PIPPERACILLIN 4-5 gm IV q 8 h or CEFTAZIDIME (covers pseudomonas) +/-GENTAMICIN Pneumonia with suspected aspiration: same as above but add CLINDAMYCIN 600 mg IV q 8 h. Oral fungal infections. NYSTATIN 5-10 cc oral swish and swallow QID. Candida Cystitis: Susceptible if patient is neutropenic or with long time foley catheter. AMPHOTERICIN B : 20 mg in 200cc sterile water. Infuse into bladder QD 3-5 days. Disseminated fungal infections AMPHOTERICIN B 0.3-1 mg/kg every day. PROPHYLAXIS: other antibiotics are on-board for anticipated infections. Heart Valve Replacement: CEFUROXIME 24-48 hours. If allergic to cephalosporins. VANCOMYCIN Orthopedics: Total joints Post-traumatic open fracture. CEFAZOLIN (ANCEF)+ GENTAMICIN Abdominal Surgery/ Post Abdominal Trauma CEFOTETAN or CLINDAMICIN and GENTAMICIN Staph Aureaus skin flora and B. Fragilis bowel (anaerobe). Ventriculostomy Placement: NONE "The Antibiotic Order Form" must be completed prior to administration of antimicrobial therapy."

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