Infectious Diseases in Critical Care (eBook)

Preface 5
Contents 6
List of Contributors 18
General Aspects 23
Approach to the Febrile Patient in the Intensive Care Unit 24
Cardiovascular Monitoring in Severe Sepsis or Septic Shock 32
Cardiopulmonary Resuscitation and Infection 43
Opportunistic Infections in the Intensive Care Unit: A Microbiologic Overview 50
Infections in Critically Ill Solid Organ Transplant Recipients 56
HIV in the Intensive Care Unit 72
Fungal Infections 86
Using Protocols To Improve the Outcomes of Critically Ill Patients with Infection: Focus on Ventilator- Associated Pneumonia and Severe Sepsis 99
Microbial Surveillance in the Intensive Care Unit 106
Use of Anti- infective Therapy in Critically Ill Patients 111
Antimicrobial Prophylaxis in the Intensive Care Unit 112
Antifungal Therapy in the Intensive Care Unit 119
Dose Adjustment and Pharmacokinetics of Antibiotics in Severe Sepsis and Septic Shock 141
Prescription of Antimicrobial Agents in Patients Undergoing Continuous Renal Replacement Therapy 166
Methods for Implementing Antibiotic Control in the Intensive Care Unit 178
Use of Antibiotics in Pregnant Patients in the Intensive Care Unit 187
Immunomodulation in Sepsis 202
Antibiotic Induced Diarrhea 210
Infection Control/ Epidemiology 216
Fundamentals of Infection Control and Strategies for the Intensive Care Unit 217
Antibiotic Resistance in the Intensive Care Unit 230
Epidemiology of Pseudomonas aeruginosa in the Intensive Care Unit 236
How To Control MRSA Spread in the Intensive Care Unit 244
Epidemiology of Acinetobacter baumannii in the Intensive Care Unit 251
Bloodstream Infections and Infection Disease Emergencies 258
Brain Abscess 259
Falciparum Malaria 268
Toxic Shock Syndromes 279
Acute Infective Endocarditis 287
Influenza 300
Bloodstream Infection in the Intensive Care Unit 308
Bloodstream Infections in Patients with Total Parenteral Nutrition Catheters 319
Hemodialysis Catheter- Related Infections 329
Infection of Pulmonary Arterial and Peripheral Arterial Catheters 340
Prevention of Catheter- Related Bloodstream Infections in Critical Care Patients 349
Meningococcemia 357
Septic Shock 388
Respiratory Infections 399
Tracheobronchitis in the Intensive Care Unit 400
Severe Community- Acquired Pneumonia 409
Legionnaires’ Disease 419
Adjunctive and Supportive Measures for Community- Acquired Pneumonia 428
Respiratory Infection in Immunocompromised Neutropenic Patients 435
Pneumonia in Non- Neutropenic Immuno- compromised Patients 442
Community- Acquired Respiratory Complications in the Intensive Care Unit: Pneumonia and Acute Exacerbations of COPD 450
Management of Hospital- Associated Pneumonia in the Intensive Care Unit 464
Assessment of Resolution of Ventilator Associated Pneumonia 471
Invasive Devices in the Pathogenesis of Nosocomial Pneumonia 481
Infections with Surgical Implications 490
Multiple Organ Dysfunction Syndrome 491
Sepsis in Obstetrics 502
Diagnosis and Management of Intra- abdominal Sepsis 508
Surgical Site Infection Control in the Critical Care Environment 523
Severe Soft Tissue Infections: A Syndrome- Based Approach 535
Vascular Graft Infections 545
Acute Mediastinitis 556
Pancreatic Infection 569
Urinary Tract Infections 581
Neurosurgical Infections in Intensive Care Unit Patients 595
Biliary Tract Infections 609
Subject Index 620

"35 Tracheobronchitis in the Intensive Care Unit (p. 385-386)

L. Morrow, D. Schuller

35.1 Introduction

Tracheobronchitis can be broadly defined as inflammation of the airways between the larynx and the bronchioles. Clinically, this syndrome is recognized by an increase in the volume and purulence of the lower respiratory tract secretions and is frequently associated with signs of variable airflow obstruction. In the intensive care unit (ICU), tracheobronchitis is a relatively common problem with an incidence as high as 10.6% [1]. Although tracheobronchitis is associated with a significantly longer length of ICU stay and a prolonged need for mechanical ventilation, it has not been shown to increase mortality.

These outcomes can be improved through the use of antimicrobial agents [1]. Tracheobronchitis results fromtwo dominating processes: colonization of the oropharynx and its contiguous structures (dental plaque, the sinuses, the stomach) by potentially pathogenic organisms and aspiration of contaminated secretions from these anatomic sites [2]. Mechanically ventilated patients are particularly at risk for tracheobronchitis given the presence of an endotracheal tube.

These devices contribute to the pathogenesis of tracheobronchitis (and pneumonia) in a variety of manners: bypassing natural host defenses, acting as a nidus for biofilm formation, allowing pooled secretions and bacteria to leak around the cuff and into the trachea, damaging the ciliated epithelium and reducing bacterial clearance directly or via frequent suctioning to maintain airway patency [3, 4]. In contrast to nosocomial pneumonia, nosocomial tracheobronchitis does not involve pulmonary parenchyma and, thus, does not cause radiographic pulmonary infiltrates. However, high quality portable chest radiographs may be difficult to obtain in the ICU, where poor patient cooperation, inconsistent technique and other obstacles lead to suboptimal studies [5].

Furthermore, common processes such as atelectasis, pulmonary edema, or pleural effusions can cause infiltrates that mimic pneumonia making the clinical distinction between pneumonia and tracheobronchitis difficult [6].

35.2 Bacterial Tracheobronchitis

Bacterial infection is the most common cause of infectious tracheobronchitis in the ICU. Infectious tracheobronchitis is clinically diagnosed when a patient develops fever, purulent respiratory secretions, and leukocytosis but the chest radiograph shows no new infiltrate [7].  Tracheobronchitis is “microbiologically confirmed” when a patient with clinically diagnosed tracheobronchitis yields culture specimens that identify a causative pathogen at appropriately high densities.

When a patient lacks fever or leukocytosis (or if culture specimens reveal few organisms) the differentiation between colonization and infection is difficult and controversial. Furthermore, the significance of tracheobronchial colonization as a risk factor for subsequent lower respiratory tract infection remains unclear.

Alterations in the oropharyngeal flora of the hospitalized host have been associated with several factors including age, severity of acute illness, comorbid chronic illnesses, and duration of hospitalization [8–10]. One study of outpatients with chronic tracheostomy concluded that although these patients were routinely colonized with massive amounts of potentially pathogenic bacteria, rates of severe respiratory tract infections were low [11]."