如何判读重症患者新发发热？.ppt

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,Nosocomial infection(,医院感染,),国外：,Hospital associated infection,，,Hospital acquired infection,，,Hospital infection,，,Nosocomial infection,等。目前常用的是后三者；,国内，曾先用过,“,医学性感染,”,，,“,医院获得性感染,”,，,“,医院内感染,”,等，近年来逐渐统一称为,“,医院感染,”,。,2025/11/12 周三,2,Anywhere-when do you touch?,2025/11/12 周三,3,一般共识：,1,医院感染应以住院病人作为主要分析判断的对象。在实际中，以在医院感染发生率进行统计。,只有明确根据说明系在住院期间感染而出院后才出现症状的，才能将其列入。,2,医院感染的统计，不包括病人在入院前已开始或入院时已处于潜伏期的感染。若病人这次住院前和入院后的感染是在前次住院期间所得，亦列为医院感染。由于潜伏期幅度多有变化值，尤其是潜伏期不明者而难于确定时，在统计时，以入院后,48,小时内发生的，列为医院感染。,3,确认为医院感染者，应有诊断的依据，并按统一的标准作出诊断。,Whats Nosocomial infection,？,Evaluation System,Fever Evaluation,Measuring Body Temperature and Defining Fever as Thresholds for Diagnostic Effort.,Recommendations for Measuring Temperature,1.,Choose the most accurate and reliable method to measure temperature based on the clinical circumstances of the patient.Temperature is most accurately measured by an intravascular,esophageal,or bladder thermistor,followed by rectal,oral,and tympanic membrane measurements,in that order(Table 2),.,Axillary measurements,temporal artery estimates,and chemical dot thermometers should not be used in the ICU(level 2).Rectal thermometers should be avoided in neutropenic patients(level 2).,Recommendations for Measuring Temperature-1,Recommendations for Measuring Temperature-2,2.Any device used to measure temperature must be maintained and calibrated appropriately,using the manufacturers guidelines as a r eference(level 2).,3.Any device used to measure temperature must be used in a manner that does not facilitate spread of pathogens by the i nstrument or the operator(level 2).,4.The site of temperature measurement should be recorded with the temperature in the chart(level 1).,5.A new onset of temperature of 38.3C is a reasonable trigger for a clinical assessment but not necessarily a laboratory or radiologic evaluation for infection(level 3).,6.A new onset of temperature of 36.0C in the absence of a known cause of hypothermia(e.g.,hypothyroidism,cooling blanket,etc.)is a reasonable trigger for a clinical assessment but not necessarily a laboratory or radiologic evaluation for infection(level 3).,7.Critical care units could reduce the cost of fever evaluations by eliminating automatic laboratory and radiologic tests for patients with new temperature elevation(level 2).Instead,these tests should be ordered based on,clinical assessment.A clinical and labo-ratory evaluation for infection,con-versely,may be appropriate in euther-mic or hypothermic patients,depending on clinical presentation.,Recommendations for Measuring Temperature-3,Blood Cultures,Blood culture system,Recommendations for Obtaining Blood Cultures,Blood culture system,Recommendations for Obtaining Blood Cultures-1,1.,Obtain three to four blood cultures within the first 24 hrs of the onset of fever.Every effort must be made to draw the first cultures before the initiation of antimicrobial therapy.They can be drawn consecutively or simultaneously,unless there is suspicion of an endovascular infection,in which case separate venipunctures by timed intervals can be drawn to demonstrate continuous bacteremia(level 2).,2.,Additional blood cultures should be drawn thereafter only when there is clinical suspicion of continuing or recurrent bacteremia or fungemia or for test of cure,48 96 hrs after initiation of appropriate therapy for bacteremia/fungemia.Additional cultures should not be drawn as a single specimen but should always be paired(level 2).,Recommendations for Obtaining Blood Cultures-2,3.,For patients without an indwelling vascular catheter,obtain at least two blood cultures using strict aseptic,technique from peripheral sites by separate venipunctures after appropriate disinfection of the skin(level 2).,4.,For cutaneous disinfection,2%chlorhexidine gluconate in 70%isopropyl alcohol is the preferred skin antiseptic,but tincture of iodine is equally effective.Both require 30 secs of drying time before proceeding with the culture procedure.Povidone iodine is an acceptable alternative,but it must be allowed to dry for 2 mins(level 1).,Recommendations for Obtaining Blood Cultures-3,5.,The injection port of the blood culture bottles should be wiped with 70 90%alcohol before injecting the blood sample into the bottle to reduce the risk of introduced contamination(level 3).,6.,If the patient has an intravascular catheter,one blood culture should be drawn by venipuncture and at least,one culture should be drawn through an intravascular catheter.Obtaining blood cultures exclusively through,intravascular catheters yields slightly less precise information than information obtained when at least one,culture is drawn by venipuncture(level 2).,Recommendations for Obtaining Blood Cultures-4,7.,Label the blood culture with the ex-act time,date,and anatomic site from which it was taken(level 2).,8.,Draw 20 30 mL of blood per culture(level 2).,9.,Paired blood cultures provide more useful information than single blood cultures.Single blood cultures are not recommended,except in neonates(level 2).,10.,Once blood cultures have been obtained after the onset of new fever,additional blood cultures should be,ordered based on clinical suspicion of continuous or recurrent bacteremia or fungemia(level 2).,Intravascular Devices and Fever,Recommendations for Management of Intravascular Catheters,Recommendations for Management of Intravascular Catheters-1,1.,Examine the patient at least daily for inflammation or purulence at the exit site or along the tunnel,and assess the patient for signs of venous thrombosis or evidence of embolic phenomena(level 2).,2.,Any expressed purulence from the insertion site should be Gram stained and cultured(level 2).,3.,If there is evidence of a tunnel infection,embolic phenomenon,vascular compromise,or septic shock,the,catheter should be removed and cultured and a new catheter inserted at a different site(level 2).,4.,With short-term temporary cathetersperipheral venous catheters,noncuffed central venous catheters,or arterial cathetersif catheter-related sepsis(i.e.,source of the infection is a colonized catheter)is considered likely,the suspect catheter or catheters should be removed and a catheter segment cultured.Blood cultures should be obtained as well.With all short-term catheters,a 5-to 7-cm intracutaneous segment should be cultured to document the source of bacteremia;with short peripheral venous,or arterial catheters,the tip should be cultured;with longer central venous catheters,the intracutaneous segment,and tip should be cultured;and with pulmonary artery catheters,the introducer and the pulmonary artery catheter should be cultured(level 1).,Recommendations for Management of Intravascular Catheters-2,5.,At least two blood cultures should be obtained.At least one blood culture should be obtained peripherally by venipuncture.One specimen should be obtained from the suspected catheter(level 1).If a quantitative culture system is available,it should be used to diagnose the catheter as the source of bacteremia/fungemia.Alternatively,differential time to positivity can be used if both blood cultures are positive for the same organism.The distal port is the logical port from which to draw cultures.When short-term,uncuffed central venous catheters are suspected of infection,it is usually more efficient to remove the existing catheter and replace it than to draw quantitative cultures(level 2).,Recommendations for Management of Intravascular Catheters-2,6.,Do not routinely culture all catheters removed from ICU patients.Culture only those catheters suspected of being the source of infection(level 2).,7.,It is not necessary to routinely culture,infusate specimens as part of the evaluation for catheter-related infections,unless there is clinical suspicion for infected infusate or blood products(level 2).,Recommendations for Management of Intravascular Catheters-3,Pulmonary Infections and ICU-Acquired Pneumonia,Recommendations for Evaluation of Pulmonary Infections.,-If a febrile patient is suspected of having a lower respiratory tract infection by clinical or radiographic assessment:,Recommendations for Evaluation of Pulmonary Infections-1,1.,A chest imaging study should be obtained.In most cases,an upright portable anteroposterior chest radiograph is the most feasible study to obtain.Posterior-anterior chest radiographs with lateral view or CT scan offer more infor-,mation and should be obtained when clinically indicated,especially to rule out opportunistic infections in immu-,nocompromised patients(level 1).,2.Obtain one sample of lower respira-tory tract secretions for direct exami-nation and culture before initiation of or change in antibiotics.Expectorated sputum,induced sputum,tracheal se-cretions,or bronchoscopic or nonbron-choscopic alveolar lavage material can be used effectively.,Recommendations for Evaluation of Pulmonary Infections-2,If pneumonia is documented by physical examination,and radiographic evaluation,a deci-sion to employ bronchoscopy or other invasive diagnostic approaches should be considered based on an individual,basis and the availability of local ex-pertise(level 2).,3.Respiratory secretions obtained for microbiological evaluation should be transported to the laboratory and pro-,cessed in 2 hrs(level 2).,4.Respiratory secretions that are judged to be appropriate samples by the laboratory should be evaluated by Gram-,negative stain and cultured for routine aerobic and facultative bacteria.,Recommendations for Evaluation of Pulmonary Infections-3,Additional stains,rapid tests,cultures,and other tests should be performed as epidemiologically appropriate(level 2).,5.Quantitative cultures can provide useful information in certain patient populations laboratories;however,quantitative cultures have not yet been sufficiently,standardized nor have they been shown to alter outcome for this technique to be considered part of routine,evaluation(level 2).,6.Pleural fluid should be obtained with ultrasound guidance for Gram-negative stain and routine culture(with,other studies as clinically indicated)if there is an adjacent infiltrate or another reason to suspect infection and the fluid,can be safely aspirated(level 2).,Stool Evaluation in the FebrilePatient in the ICU,Recommendations for Evaluation of the Gastrointestinal Tract.,-If more than two stools per day conform to the con-tainer in which they are placed in a patient at risk for C.difficileand if clinical evaluation indicates that a laboratory evaluation is necessary:,Recommendations for Evaluation of the Gastrointestinal Tract-1,Send one stool sample for C.,difficile,common antigen,EIA for toxin A and B,or tissue culture assay(level 2).,2.If the first specimen for C.,difficile,is negative and testing is performed by an EIA method,send an additional sample for C.,difficile,EIA evaluation.A second specimen is not necessary if the common antigen test was negative(level 2).,3.If severe illness is present and rapid tests for C.,difficile,are negative or unavailable,consider flexible,sigmoidoscopy,(level 3).,4.If severe illness is present,consider empirical therapy with vancomycin while awaiting diagnostic studies.Empirical therapy is not generally recommended if two stool evaluations are negative using a reliable assay.Although it may be more cost-effective than making the diagnosis,the empirical use of antibiotics,especially vancomycin,is discouraged because of the risk of producing resistant pathogens(level 2).,5.Stool cultures for other enteric pathogens are rarely indicated in a patient who did not present to the hospital,with diarrhea or in patients who are not HIV infected.,Recommendations for Evaluation of the Gastrointestinal Tract-2,Send stool cultures for other enteric pathogens and examine for ova and parasites only if epidemiologically appropriate or evaluating an immunocompromised host(level 2).,6.Test stool for norovirus if the clinical and epidemiologic setting is appropriate.Testing for norovirus is usually only available in state laboratories and is usually performed in outbreak settings.Obtain consultation with infection control and public health authorities(level 3),.,Recommendations for Evaluation of the Gastrointestinal Tract-3,Urinary Tract Infection,Recommendations for Evaluation of the Urinary Tract,Recommendations for Evaluation of the Urinary Tract-1,1.,For patients at high risk for urinary tract infection(kidney transplant patients,granulocytopenic patients,or patients with recent urologic surgery or obstruction),if clinical evaluation suggests a patient may have symptomatic urinary tract infection,a laboratory evaluation is necessary.Obtain urine for microscopic exam,Gram-negative stain,and culture(level 2).,2.,Patients who have urinary catheters in place should have urine collected from the sampling port of the catheter and not from the drainage bag(level 2).,Recommendations for Evaluation of the Urinary Tract-2,3.Urine should be transported to the laboratory and processed within 1 hr to avoid bacterial multiplication.If,transport to the laboratory will be delayed for 1 hr,the specimen should be refrigerated.Alternatively,a preservative could be used but is less preferable to refrigeration(level 2).,4.Cultures from catheterized patients showing 10,3,cfu/mL represent true bacteriuria or candiduria,but neither higher counts nor the presence of pyuria alone are of much value in determining if the catheter-associated bacteriuria or candiduria is the cause of a patients fever;in most cases,it is not the cause of fever(level 1).,Recommendations for Evaluation of the Urinary Tract-3,5.Gram stains of centrifuged urine will reliably show the infecting organisms and can aid in the selection of anti-,infective therapy if catheter-associated urosepsis is suspected(level 1).,6.Rapid dipstick tests are not recommended for patients with urinary catheters in the analysis of possible catheter-associated infection(level 1).,Sinusitis,Recommendations for Evaluation of the Sinuses,Recommendations for Evaluation of the Sinuses,1.,If clinical evaluation suggests that sinusitis may be a cause of fever,a CT scan of the facial sinuses should be obtained(level 2).,2.,If the patient has not responded to empirical therapy,puncture and aspiration of the involved sinuses under,antiseptic conditions should be performed(level 2).,3.,Aspirated fluid should be sent for Gram-negative stain and culture for aerobic and anaerobic bacteria and fungi to determine the causative pathogen and its antimicrobial susceptibility(level 1).,Postoperative Fever,Recommendations for Evaluation of Fever Within 72 Hours of Surgery,Recommendations for Evaluation of Fever Within 72 Hours of Surgery-1,1.,A chest radiograph is not mandatory during the initial 72 hrs postoperatively if fever is the only indication(level 3).,2.,A urinalysis and culture are not mandatory during the initial 72 hrs post-operatively if fever is the onl