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ICU Infectious Disease Pearls and Pet Peeves-Part3: These are some extra points & random thoughts regarding commonly used antimicrobials & frequently encountered ID scenarios in the ICU. Comments from ID & Pharm friends are welcome as what I post comes from memory. Here it goes:
1. Especially in immunosuppressed patients with severe septic shock, don’t be in a hurry to de-escalate the antibiotics when the Microbiology lab calls you to report a positive blood culture result. In a number of patients, likely close to 5%, the bacteremias can be polymicrobial
2. The role of anaerobes in aspiration pneumonia is probably over-rated. Not much else to say here since the topic is extensively discussed recently. The message is that anaerobic coverage is frequently redundant. In addition, there is a huge debate about...
...what is just aspiration and what is aspiration pneumonia and, therefore, needs antibiotic treatment, so I will not put myself in this rabbit hole…
3. If your pt with "urosepsis" is not improving as “fast” as expected, don’t escalate the antibiotics without - if not done already - first ruling out hydronephrosis (among other local complications, such as emphysematous pyelo etc). POCUS can be your friend here and...
... in ~10-20% of cases will reveal an obstruction that, if not relieved, will not let the patient improve fast (or at all..)
4. In the above scenario, ask your urologist or IR colleague to get a urine sample for culture. It is not uncommon to have a “benign”/negative urine analysis/culture just because the urine previously sent was “below” and NOT above the obstruction.
5. Be prepared: pt may get worse when urinary tract manipulation takes place. It’s common practice for all these pts to receive amp+genta prophylaxis even if they have 10 previous cultures w bugs resistant to amp+genta. Make sure the pt receives the appropriate pre-op antibiotics
6. In general, prophylaxis in cases going to the OR is frequently weird... I understand that the pt has to receive the antibiotic just before the procedure but I see all the time pts leaving the ICU to go to the OR with their meropenem infusion running and when...
...they arrive in the OR 5 minutes later they receive a dose of cefazolin. This is the equivalent of dropping a nuclear bomb and then firing a shot on top of it. If you are covering the ICU, notify your friend anesthesiologist accordingly
7. I know that in this scenario all pts get antibiotics - no matter what - but we should all know that bilateral cellulitis is not common and we are actually dealing with stasis dermatitis
8. Short antibiotic courses (< 1 wk) in critically ill pts w intra-abd infections are in general as good as 15d courses. But treatment has to be individualized. If pt remains septic d post-op, don’t give another wk of anibiotics waiting for a miracle to happen. Get a CT abdomen…
9. There is a big discussion if the surgeon should send peritoneal fluid for culture. My take on this is that if the pt is sick enough to come to the ICU, I need as much info as possible to provide good care. In that sense, especially for...
...critically ill pts with hospital-acquired intra-abd ominal infections (IAIs) or community-acquired ones at risk for resistant pathogens, I expect the surgeon to send a specimen
10. Side note here: expect/demand/kindly ask the surgeon to give you sign-out in a reasonable time-frame. I don’t send a patient to the OR without notifying the surgeon first. Why am I supposed to take a patient in the ICU if I have no idea about what happened in the OR?
11. In the context of IAIs, extended-spectrum beta-lactamases (ESBL)-producing Enterobacteriaceae present a rising threat. For years now, carbapenems are considered the antibiotics of choice for ESBLs. Many colleagues think ertapenem is the best option for targeting ESBLs; just..
...remember that ertapenem lacks coverage of Pseudominas aeruginosa
12. Speaking of carbapenems, another side note: is there any reason to have imipenem still in your hospital's formulary? Besides being a cost issue… (I have no conflict of interest here)
13. Regarding carbapenems and KPC-producing bugs, like Klebs pneumoniae (especially if you don't have the fancy ceftazidime/avibactam or ceftolozone/tazobactam in your hospital): you can -sometimes- use combinations of 2 carbapenems... 😱
... (ie: ertapenem + [doripenem or meropenem]). The rationale is that ertapenem is the carbapenem w the least in vitro activity against KPC(+) K. pneumo & by using it as a suicide molecule, doripenem, likely the most potent carbapenem in regard to enzyme stability, can do the job
14. Tigecycline is a pretty good drug w quite extensive antimicrobial spectrum & works well in intra-abd infections. Most intensivists don’t keep it in their working memory until the ID consultant offers it as an option. There are though some things that need to be known about T:
... i) it is not a great option for bacteremias, ii) the usually proposed doses (50-100 mg) are a joke (just double them), iii) if the pt on T becomes septic, be aware of bugs that can usually appear in this scenario: Proteus, Morganella, Providencia, Pseudomonas
15. If the 80 yo frail patient, nursing home resident, w the 3rd UTI this year and recurrent C diff is re-admitted at 5 pm with drowsiness & what looks to be another C diff episode, have a low threshold to place a NGT and start po vanco. I can guarantee you that if you don’t,...
... she will likely choke and when you see her the next morning, she will have received no po vanco in the meantime and you will also have an aspiration (pneumonia) to deal with...
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