II. Pathophysiology
- See Fever
-
Fever is a sign of systemic inflammation, and is NOT synonymous with infection
- Not all Nosocomial Fever is infectious
- Healthcare staff are a significant source of Nosocomial Infection
- Protect patients with proper Hand Hygiene and Personal Protection Equipment (mask, gloves)
III. Risk Factors: Nosocomial Infection
- Prolonged ICU length of stay
- Gastric acid suppression (e.g. H2 Blockers, Proton Pump Inhibitors)
- Tracheostomy Tube
- Nasogastric Tube
- Intravenous catheters (esp. Central Lines)
- Endotracheal Intubation and Mechanical Ventilation
- Foley Catheters
- Recent surgery or implanted devices
- Surgical Site Infection (SSI) risk
IV. Exam
-
Temperature measurement in the ICU in order of accuracy
- Pulmonary artery, Esophagus or Bladder catheters with thermistors (preferred)
- Rectal Temperature (avoid in Neutropenia)
- Oral Temperature
- Tympanic MembraneTemperature
- Avoid axillary and temporal artery Temperatures (too low accuracy)
-
Fever thresholds
- Body Temperature >38.0 C (100.4 F) in Immunocompromised (esp. Neutropenia)
- Body Temperature >38.3 C (101.0 F) in other patients
V. Causes: Noninfectious Fever Causes (50% of cases)
- Common
- Systemic Inflammatory Response (SIRS)
- Tissue injury (major injury, tissue ischemia or infarction)
- Gastrointestinal release of inflammatory Cytokines and Endotoxin
- Acute Respiratory Distress Syndrome (ARDS)
- Early Postoperative Fever
- Major surgery
- Results in fever in 15-40% on postoperative day 1 (most without infection)
- Major surgery related early fever resolves in first 24-48 hours (if not infectious)
- Malignant Hyperthermia (Anesthetic induced)
- Atelectasis is NOT a cause of fever
- Atelectasis is coincidental with Post-operative Fever and resolves in the same timeline
- Major surgery
- Venous Thromboembolism
- Red Blood Cell Transfusion
- Occurs in 0.5% of RBC Transfusions, typically within first 6 hours
- Platelet Transfusion
- Occurs in 30% of Platelet Transfusions, related to antibodies to donor Leukocytes
- Systemic Inflammatory Response (SIRS)
- Uncommon
- Drug-Induced Fever
- Hypersensitivity Reaction (associated with Eosinophilia, rash)
- Idiosyncratic Reaction
- Drug-Induced Hyperthemia Syndromes (Muscle rigidity and fever >40 C)
- Acalculous Cholecystitis (1.5% of ICU patients)
- Thyrotoxicosis
- Acute Addisonian Crisis (Adrenal Hemorrhage)
- Iatrogenic fever
- Malfunctioning Temperature regulator on water mattress or Ventilator humidifier
- Drug-Induced Fever
VI. Causes: Nosocomial Infectious Fever Causes (50% of cases)
- Mnemonic (4Ws): Wind (Pneumonia), Water (UTI), Wound, Wires (IV)
-
Gram Negative Bacteria (often with multi-drug resistance) account for >30% of Nosocomial Infections
- Pseudomonas aeruginosa
- Burkholderia cepacia
- Stenotrophomonas maltophilia
- Acinetobacter baumannii
- Common (76-78% of Nosocomial Infections)
- Nosocomial Pneumonia
- Intubated patients account for 83% of Nosocomial Pneumonia cases in ICU
- Urinary Tract Infection
- Indwelling Foley Catheters account for 97% of nosocomial Urinary Tract Infections in ICU (CAUTI)
- Bloodstream infections
- Central Line-Associated Bloodstream Infections account for 87% of bloodstream infections
- Surgical Site Infections
- Occurs at day 5-7 after surgery, with fever typically suggesting deep space infection
- Necrotizing Soft Tissue Infection have onset within days of surgery and rapidly progress
- Nosocomial Pneumonia
- Uncommon
- Intubation Associated Sinusitis
- Associated with Nasotracheal tubes and Nasogastric Tubes
- Clostridium difficile Infection
- Consider patient specific predispositions for infection (e.g. Cirrhosis related Spontaneous Bacterial Peritonitis)
- Intubation Associated Sinusitis
VII. Labs
- Laboratory testing should be directed at most likely causes (50% of cases are non-infectious)
-
Blood Cultures
- Obtain in all cases in which infectious cause is thought to be most likely
- Obtain at least 2 sets of Blood Cultures (each with 20-30 ml split over aerobic and anaerobic bottles)
VIII. Management: General
-
Temperature lowering
- Fever is not typically harmful, but is uncomfortable
- Acetaminophen 650 mg every 4-6 hours oral or rectal as needed
- Measures to avoid in Temperature lowering
- Avoid cooling blankets (outside of hyperthermia syndromes)
- Avoid NSAIDs in the Intensive Care unit
IX. Management: Empiric Antibiotics
- Indications
- Infectious cause is thought most likely (50% of cases)
- Neutropenic patients (Absolute Neutrophil Count <500/mm3)
- Do not delay empiric therapy
- Empiric Antibiotic selection in the Intensive Care unit
- Broad spectrum Antibiotics that also cover Aerobic Gram Negative Rods
- Piperacillin/Tazobactam (Zosyn)
- Carbapenem (Imipenem or Meropenem)
- Cefepime
- Staphylococcus Coverage Indicated in suspected Central Line-Associated Bloodstream Infection
- Vancomycin (avoid in cases where MRSA in unlikely)
- Linezolid (may be preferred in decreased Renal Function)
- Disseminated Candidiasis coverage indicated in Prolonged Fever (>3 days), Immunocompromised, recent Antibiotics
- Fluconazole (first-line)
- Caspofungin (Neutropenia)
- Broad spectrum Antibiotics that also cover Aerobic Gram Negative Rods
-
Antibiotics to avoid
- Fluoroquinolones
- Increased Antibiotic Resistance, Clostridium difficile, Neuropathy, Tendinopathy and Delirium
- Aminoglycosides
- Increased nephrotoxicity, without significant benefit from double coverage of Gram Negative Bacteria
- Fluoroquinolones
X. Resources
- Internet Book of Critical Care (EMCRIT.org)
XI. References
- Marino (2014) The ICU Book, p. 777-95
Images: Related links to external sites (from Bing)
Related Studies
Definition (SCTSPA) | Infección asociada con una hospitalización, que no estaba presente ni en período de incubación antes de la admisión, y que generalmente se manifiesta después de más de 72 horas desde el ingreso |
Definition (SNOMEDCT_US) | Infection associated with hospitalization, not present or incubating prior to admission, but generally occurring more than 72 hours after admission |
Definition (CSP) | pertaining to or originating in the hospital; an infection not present or incubating prior to admittance to the hospital; usually used to refer to patients, but hospital personnel may also acquire nosocomial infection. |
Concepts | Disease or Syndrome (T047) |
MSH | D003428 |
SnomedCT | 198051006, 19168005 |
English | Hospital Infection, Hospital Infections, Infection, Hospital, Infection, Nosocomial, Infections, Nosocomial, Nosocomial Infection, Nosocomial Infections, nosocomial infection, INFECT NOSOCOMIAL, INFECT HOSP, NOSOCOMIAL INFECT, HOSP INFECT, institutional infection, Hospital acquired infection, Hospitalization-associated infection, hospital infection, hospital acquired infection, hospital infections, nosocomial infections, Nosocomial infection (disorder), Hospitalisation-associated infection, Nosocomial infections, Nosocomial infectious disease, Nosocomial infection, Nosocomial infectious disease (disorder), Nosocomial infectious disease, NOS, Infections, Hospital |
Italian | Infezione nosocomiale, Infezione ospedaliera, Infezioni nosocomiali, Infezioni ospedaliere |
Dutch | hospital-acquired infectie, ziekenhuisopnamegeassocieerde infectie, ziekenhuisinfectie, Nosocomiale infectie, Ziekenhuisinfectie |
French | Infection acquise en milieu hospitalier, Infection liée à l'hospitalisation, Infections hospitalières, Infection nosocomiale, Infections nosocomiales |
German | mit der Hospitalisierung assoziierte Infektion, im Krankenhaus erworbene Infektion, Hospitalinfektionen, Nosokomialinfektion, Hospitalismus, Nosokomiale Infektionen |
Portuguese | Infecção associada a hospitalização, Infecção nosocomial, Infecções Nosocomiais |
Spanish | Infección hospitalaria, Infección adquirida en el hospital, infección intrahospitalaria (trastorno), infección intrahospitalaria, enfermedad infecciosa adquirida en el hospital, enfermedad infecciosa nosocomial (trastorno), enfermedad infecciosa nosocomial, Infección intrahospitalaria, Infecciones en Hospitales, Infecciones Nosocomiales |
Japanese | 院内感染, インナイカンセン |
Czech | nosokomiální infekce, nemocniční infekce, nozokomiální infekce, Infekce získaná při hospitalizaci, Nozokomiální infekce, Infekce získaná v nemocnici |
Hungarian | nosocomialis fertőzés, Kórházban szerzett fertőzés, Hospitalizációval kapcsolatos fertőzés |
Norwegian | Nosokomiale infeksjoner, Sykehusinfeksjoner |