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#idmeded #idtips day 3 - fever in the ICU. A common scenario in patients who often can't communicate due to sedation/ventilation. Long differential, and often escalating antibiotics without a clear cause. Let's go through systematically.
1) History as always (from the chart)
1) History as always (from the chart)
Physical - examine all catheter sites, and head to toe examination. Look at underside for wounds. Examine all joints extensively (more to come). Look at teeth and eyes. Look at ins/outs
Labs - work through the differential - blood cultures from lines at a minimum
Labs - work through the differential - blood cultures from lines at a minimum
What's the differential - infectious
Easy ones - central lines, ventilator associated pneumonia, wound infections (post surgical/pressure) +/- underlying osteomyelitis, clostridium difficile
Less likely - CNS infections, non ulcer associated bone and joint infections
Easy ones - central lines, ventilator associated pneumonia, wound infections (post surgical/pressure) +/- underlying osteomyelitis, clostridium difficile
Less likely - CNS infections, non ulcer associated bone and joint infections
What infections are missed?
1) Sinusitis - especially with long term NG feeds. Often not simple, gram negative/pyogenic. Do an examination if NG fed. If ++ nasal secretions consider imaging or rhinoscopy if not improving.
2) Dental/parotid infections with long admits
1) Sinusitis - especially with long term NG feeds. Often not simple, gram negative/pyogenic. Do an examination if NG fed. If ++ nasal secretions consider imaging or rhinoscopy if not improving.
2) Dental/parotid infections with long admits
Other considerations
1) Nosocomial viral infections including but not limited to COVID-19 (test appropriately)
2) Secondary fungal infections particularly in the post influenza patient (Imagine and bronchoscopy)
3) Reactivations of underlying infections - MTB, strongy, CMV
1) Nosocomial viral infections including but not limited to COVID-19 (test appropriately)
2) Secondary fungal infections particularly in the post influenza patient (Imagine and bronchoscopy)
3) Reactivations of underlying infections - MTB, strongy, CMV
Empiric treatment is based on syndrome - but treatment is no substitute for evaluating for a source repeatedly. If patients continue to be febrile with broad spectrum abx
a) You're missing an undrained source
b) It's not infectious
c) Spectrum isn't wide enough - less likely
a) You're missing an undrained source
b) It's not infectious
c) Spectrum isn't wide enough - less likely
So non infectious etiologies - consider these
1) Central fevers - esp in brain injury/bleed. high fevers, chaotic, unabating with NSAIDs
2) Hepatobiliary - acalculous choly or pancreatitis - make sure you send liver enzymes/lipase!
3) Drugs - beta lactams, neurotropics, anti sz
1) Central fevers - esp in brain injury/bleed. high fevers, chaotic, unabating with NSAIDs
2) Hepatobiliary - acalculous choly or pancreatitis - make sure you send liver enzymes/lipase!
3) Drugs - beta lactams, neurotropics, anti sz
4) Bleeding - trend hemoglobins, blood can hide and be pyrogenic! Rectus sheath, retroperitoneum, post surgical.
5) VTE - maybe - controversial if truly pyogenic.
6) Infarcted tissue
7) GOUT - I've picked this up repeatedly. Diuretics, renal failure. Knee/Toes not examined.
5) VTE - maybe - controversial if truly pyogenic.
6) Infarcted tissue
7) GOUT - I've picked this up repeatedly. Diuretics, renal failure. Knee/Toes not examined.
Bottom line head to toe physical. Send tests based on differential. Liver enzymes/lipase should be sent on most. Examine all your joints.
If antibiotics aren't working - adding more doesn't necessarily help - more that you have to circle back to your initial diagnosis.
If antibiotics aren't working - adding more doesn't necessarily help - more that you have to circle back to your initial diagnosis.
