ICU Infectious Disease Secrets:
This is another random collection from cases I took care of the last couple of months. As always, I may be wrong...
And so it begins:
1. The best time to draw blood cultures from a patient, who has just been transferred from the ward to the ICU
This is another random collection from cases I took care of the last couple of months. As always, I may be wrong...
And so it begins:
1. The best time to draw blood cultures from a patient, who has just been transferred from the ward to the ICU
& is crashing on you, is when you place “crash” central venous/arterial lines. If you don't do it yourself, either nobody will do it or it will be done much later (after antibiotics) & you will commit the nurse or the phlebotomist spending time on a task that will take you 30 sec
2. Don’t just order antibiotics for a crashing septic patient. Make sure that they are given in time. Make a plan with the nurse: “It is 9:00. If the Pharmacy has not sent the antibiotics by 9:30, please let me know and I will call them”
3. If you work in a hospital where pharmacy is not available 24/7 or is badly understaffed, it may be a good idea to ask for the antibiotics to be sent to the ICU ahead of time, even before the patient arrives. I do it all the time. Also, if you manage a very sick patient,
consider infusing the antibiotics (except for vancomycin!) much faster than the recommended infusion rate. Several antibiotics are approved for “iv push” dosing but many pharmacies still recommend infusion over 30-60 min
4. Sudden neutropenia in a pt who “is not doing well” is usually indicative of GNR bacteremia & impending sepsis. I have seen pts sent to brain CT for looking “drowsy” while their WBC had ⬇️ from 8,000 to 1,000/ml. This is sepsis until proven otherwise & usually a GNR is to blame
5. If you are an anesthesiologist colleague working in a urological procedure (eg, ureteral stent exchange) & the urologist is asking for pre-operative prophylaxis w cefazolin (Keflex in the US) or ciprofloxacin, please spend a min trying to pull previous urine cultures from EHR.
It’s quite likely that the E coli is MDR/ESBL, especially if the pt has history of recurrent UTIs. Also, if you are the urologist in the case, can you please send a urine culture? It’s kind of crazy to try to send blood cultures a few hrs post-procedure when the pt becomes septic
6. The characteristics and not the size of a pleural effusion can more reliably predict its nature. I hear often that “this effusion is small” (in CXR or CT), therefore, “it cannot be empyema”. Several years ago, a young patient of mine arrested & died. An autopsy was performed
and, among other findings, it did show a small empyema that none of us had suspected. We are perfectly fine with diagnosing and treating lung and abdominal abscesses with a diameter of 1 cm; why should empyemas be “large”?
7. In patients with an undiagnosed pleural effusion where pleural infection is possible, pleural fluid samples should be sent in plain containers as well as inoculated into (aerobic and anaerobic) blood culture bottles. In fact, if there is not enough pleural fluid,
the available sample should be prioritized to blood culture bottles rather than the plain container. This practice does not apply only to ascitic fluid samples. I have lost this battle in the hospital I work, but I hope you will succeed in yours…
8. Linezolid is a reversible inhibitor of monoamine oxidase, an enzyme responsible for breaking down serotonin; this has led to concerns for development of serotonin syndrome (SS) in pts receiving serotonergic agents (eg, SSRIs). In fact, the 🇺🇸 Food and Drug Administration
recommended a 14-days washout period in pts receiving these agents. Obviously, this is not practical in the ICU setting. The good thing is that SS is very rare when linezolid is combined with serotonergic agents. So, if Cerner (EHR) is giving you a pop-up window whenever you try
to order linezolid in a patient receiving fentanyl or citalopram, you can ignore it but remain cognizant of the interaction
9. Linezolid is an option for MRSA bacteremia. I know, it is not FDA-approved & it is not considered the preferred agent due to its bacteriostatic profile & large volume of distribution. However - and I don't say this because I have successfully used it many times, especially
in the setting of bacteremic MRSA pneumonia – some data support its use as a potential first-line drug against MRSA bacteremia (like vancomycin and daptomycin). Of course, discuss the case with your ID consultant
10. Finally, thrombocytopenia is not a contraindication for linezolid use. You can use it at least for a few days (if it is necessary) and discuss with ID about the next step
Thanks for following along!
Please excuse my typos and the abbreviations…
Please excuse my typos and the abbreviations…
Some useful references:
Clinical Infectious Diseases 2023; 77(8); 1120-25.
doi.org
fda.gov
Thorax 2023; 78(11): 1143-56. doi.org
Clinical Infectious Diseases 2009; 49(3): 395‐401. doi.org
Clinical Infectious Diseases 2023; 77(8); 1120-25.
doi.org
fda.gov
Thorax 2023; 78(11): 1143-56. doi.org
Clinical Infectious Diseases 2009; 49(3): 395‐401. doi.org
fda.gov/drugs/drug-saf…
drug interaction between linezolid and serotonergic psychiatric med...
[10/20/2011] The U.S. Food and Drug Administration (FDA) is updating the public on the potential dru...
doi.org/10.1136/thorax…
British Thoracic Society Guideline for pleural disease
The following is a summary of the British Thoracic Society (BTS) Guideline for pleural disease and i...
doi.org/10.1086/600295
Salvage Treatment for Persistent Methicillin-Resistant Staphylococcus aureus Bacteremia: Efficacy of Linezolid With or Without Carbapenem
Abstract. Background. Persistent methicillin-resistant Staphylococcus aureus (MRSA) bacteremia is as...
doi.org/10.1093/cid/ci…
Antibiotic Myths for the Infectious Diseases Clinician
Antimicrobials are commonly prescribed and often misunderstood. This narrative will focus on myths r...
Hospital Pharmacy 2018; 53(3): 157-69.
https:// doi: 10.1177/0018578718760257
Antibiotics 2023; 12(4): 697. doi.org
https:// doi: 10.1177/0018578718760257
Antibiotics 2023; 12(4): 697. doi.org
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