Gastrointestinal Infections in the ICU
Intra-abdominal infections are a major cause of morbidity, mortality and antibiotic expenditure in the ICU [21]. Accurate and timely diagnosis can have a major impact on clinical outcome, antimicrobial selection, healthcare cost and need for surgical intervention. Spontaneous bacterial peritonitis in the ICU is commonly seen in decompensated cirrhotic patients, likely due to the translocation of overgrowing enteric bacteria (usually gram negative organisms, although MRSA has been commonly described in ICU patients) across an anatomically intact gastrointestinal tract. Gastrointestinal wall perforation or ulceration can result in polymicrobial seeding into neighboring areas, resulting in signs of acute abdomen. Localized pain suggests the infection is walled-off in the area directly associated with the area of seeding, whereas diffuse pain suggests generalized peritonitis. Intra-abdominal abscesses, bowel perforation, cholecystitis, and ascending cholangitis are common ICU gastrointestinal infections. While antibiotic therapy plays an important role in the management of intra-abdominal infections, fluid resuscitation, physiologic organ system support and surgical intervention are also key factors that dramatically affect morbidity and mortality. Bladder pressure monitoring may be done to detect abdominal compartment syndrome as a complication of extensive intraperitoneal/retroperitoneal inflammation and aggressive fluid resuscitation [22]. Antibiotic therapy should be directed towards the culture results, if known. Otherwise, broad-spectrum therapy against gram-negative organisms and anaerobes (e.g., carbapenems, piperacillin-tazobactam, fluoroquinolones + metronidazole, tigecycline, 3rd/4th generation cephalosporin + clindamycin or metronidazole) should be given for 4-7 days, assuming there is adequate source control [23]. Source control is attained by adequate drainage, monitored by clinical improvement, and radiographic improvement of the fluid collection. With increasing antibiotic and antacid use in the ICU, Clostridium difficile infection (CDI) is commonly seen in critically ill patients. For patients with severe, complicated CDI, oral vancomycin (per rectum if ileus is present) with or without intravenously administered metronidazole is the treatment of choice [24]. The reason for considering combination therapy is to increase the likelihood of tissue penetration and allow for clinical response. If a patient is already clinically improving on oral or per-rectal vancomycin, the addition of metronidazole is not necessary. In patients with rising hyperlactatemia and leukocytosis ≥50,000 cells/μL, subtotal colectomy with rectal preservation should be considered.
REF:- Haley RW, Hooton TM, Culver DH, Stanley RC, Emori TG, et al. (1981) Nosocomial infections in U.S. hospitals, 1975-1976: estimated frequency by selected characteristics of patients. Am J Med 70: 947-959.
Intra-abdominal infections are a major cause of morbidity, mortality and antibiotic expenditure in the ICU [21]. Accurate and timely diagnosis can have a major impact on clinical outcome, antimicrobial selection, healthcare cost and need for surgical intervention. Spontaneous bacterial peritonitis in the ICU is commonly seen in decompensated cirrhotic patients, likely due to the translocation of overgrowing enteric bacteria (usually gram negative organisms, although MRSA has been commonly described in ICU patients) across an anatomically intact gastrointestinal tract. Gastrointestinal wall perforation or ulceration can result in polymicrobial seeding into neighboring areas, resulting in signs of acute abdomen. Localized pain suggests the infection is walled-off in the area directly associated with the area of seeding, whereas diffuse pain suggests generalized peritonitis. Intra-abdominal abscesses, bowel perforation, cholecystitis, and ascending cholangitis are common ICU gastrointestinal infections. While antibiotic therapy plays an important role in the management of intra-abdominal infections, fluid resuscitation, physiologic organ system support and surgical intervention are also key factors that dramatically affect morbidity and mortality. Bladder pressure monitoring may be done to detect abdominal compartment syndrome as a complication of extensive intraperitoneal/retroperitoneal inflammation and aggressive fluid resuscitation [22]. Antibiotic therapy should be directed towards the culture results, if known. Otherwise, broad-spectrum therapy against gram-negative organisms and anaerobes (e.g., carbapenems, piperacillin-tazobactam, fluoroquinolones + metronidazole, tigecycline, 3rd/4th generation cephalosporin + clindamycin or metronidazole) should be given for 4-7 days, assuming there is adequate source control [23]. Source control is attained by adequate drainage, monitored by clinical improvement, and radiographic improvement of the fluid collection. With increasing antibiotic and antacid use in the ICU, Clostridium difficile infection (CDI) is commonly seen in critically ill patients. For patients with severe, complicated CDI, oral vancomycin (per rectum if ileus is present) with or without intravenously administered metronidazole is the treatment of choice [24]. The reason for considering combination therapy is to increase the likelihood of tissue penetration and allow for clinical response. If a patient is already clinically improving on oral or per-rectal vancomycin, the addition of metronidazole is not necessary. In patients with rising hyperlactatemia and leukocytosis ≥50,000 cells/μL, subtotal colectomy with rectal preservation should be considered.
REF:- Haley RW, Hooton TM, Culver DH, Stanley RC, Emori TG, et al. (1981) Nosocomial infections in U.S. hospitals, 1975-1976: estimated frequency by selected characteristics of patients. Am J Med 70: 947-959.
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