Thread by @IM_Crit_

ICU Infectious Disease Pearls and Pet Peeves: I love ID (or at least I did until COVID-19 came into our lives…) and for quite some time I wanted to write a relevant thread. These are some of the simple things that I always try to keep in mind and discuss/apply during rounds:

1. It’s a shame to treat an intubated pt for “pneumonia” without ever sending a tracheal aspirate culture. It’s the equivalent of treating “urosepsis” without being bothered to send a urine culture
2. There is potential for “source control” in (some) pts with pneumonia. It is...

...called “thoracentecis” and whatever may follow it can be a game-changer!
3. Many blood cultures grow contaminants. But if you decide to ignore a blood culture (+) for Gram-negative rods or S. aureus or fungi, you play with fire
4. If your pt has (severe) diarrhea +/- ...

... leukocytosis, he can have C diff colitis even if the staff tells you that he does not pass the "sniff test"
5. C diff colitis without diarrhea is not uncommon in clinical practice, especially in critically ill patients

6. If your septic shock patient is dying on you, you can/must use combinations of broad-spectrum antibiotics (even carbapenems in the right setting!). This is not the time for antibiotic stewardship

7. If you septic shock patient is dying on you, use the highest dose of antibiotics you can use (I am referring specifically to the first doses). Don’t adjust for renal/liver function and don’t use extended infusions. Go big and/or go home

8. Don’t just “order” antibiotics when the patient is dying on you. Make sure that the antibiotics are administered

9. You should not give pip-tazo/vancomycin to everybody thinking that you have covered “everything”. The nursing home resident who is admitted with urinary tract infection for the fourth time this year may harbor carbapenem-resistant Klebsiella and/or VRE

10. S aureus in the urine may be a marker of bacteremia. Do your homework
11. Even mild back pain in a patient with S aureus bacteremia can be big-time trouble. Do your (imaging) homework asap

12. I don’t like consulting other services for no good reason but IMHO S aureus is a strong indication for ID consult (shown to decrease mortality)
13. Only using of antibiotics cannot adequately treat all episodes of sepsis. Without source control, the job is not done

14. Don’t assume that prescribing/giving good antibiotics is all you need to do. If the patient has a cardiac output of 2 liters/min, he will not probably do well. Support hemodynamics, ventilation, nutrition, etc

15. Make sure you are not missing a foreign body in the pt’s list of medical problems. This hidden metallic rod in the R ankle may be important
16. Speaking about foreign bodies: don’t leave the ones that we place in the ICU longer than needed. Get rid of central lines/Foleys

17. When a patient comes to the ICU after an exploratory laparotomy for perforated colon and 3 days later remains sick and spikes a temperature: you can bet that there is an intra-abdominal abscess in making and not a hospital-acquired pneumonia

18. Keep an open mind. Not everything that looks like an infection is truly one. Remember that right upper lobe infiltrate that proved to be secondary to a papillary muscle rupture? Or the aspiration pneumonia that was pulmonary hemorrhage?

19. Bacteria are bad. Until you start dealing with viruses…

20. ID is fun but requires a lot of study & memorizing. If you take care of critically ill patients, you need to know that enterococci are intrinsically resistant to cephalosporins, ertapenem does not reliably cover Pseudomonas and...

... daptomycin does not work for pneumonia because it is inactivated by the surfactant (you get additional points if u know that for whatever crazy reason dapto causes eosinophilic pneumonia…). Study ID like your life (and your patient’s life) depend on it

Thanks for reading!

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