Chapter 26 ICU Infections

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SECTION II • Medical and Surgical Crises

a site of infection is clearly definable, antibiotics should be chosen against the likely organisms. However, neutropenic patients frequently lack localizing signs of inflammation, and no likely source is found in most cases (even with care- ful examination). In such cases, cultures of blood, urine, sputum, and skin lesions should be obtained. Even though pyuria may be absent, microscopic examination of the urine may reveal large numbers of organisms. Broad-spectrum antibiotics, including extended-spectrum penicillin or third-generation cephalosporin plus an aminoglycoside, should be initiated. Vancomycin is warranted if the patient is allergic to penicillin, especially considering the prevalence of methicillin-resistant Staphylococci . In many centers, amphotericin or other antifungal agent is begun if the patient remains febrile for more than 72 hours after institution of broad-spec- trum antibiotics. Postsplenectomy Infections Serious infections after splenectomy usually are due to encapsulated bacteria (e.g., pneumococci, Salmonella, Haemophilus ). Loss of the spleen’s phagocytic function allows unchecked bacterial pro- liferation. Similarly, loss of hepatic phagocytic func- tion in patients with cirrhosis makes them subject to overwhelming infection. Salmonella and Vibrio species are two unusual pathogens seen in such patients. Therefore, in patients without a functional spleen (e.g., sickle cell disease), the prevention of infections and the early institution of antibiotics are essential.

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