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TRANSCRIPT
• Definitions
• Principles to approach fever or infection
• Introduction of antibiotics
• Prophylaxis
Contents
• Definitions
• Principles to approach fever or infection
• Introduction of antibiotics
• Prophylaxis
• Culture report
Contents
• Controlled by hypothalamus
• Core body temperature: 36.5℃~ 37.5 ℃
• 體溫最低時間:早上6點體溫最高時間:下午4~6點
• Oral temperature: 36.8 ℃ ± 0.4 ℃Rectal temperature: 比口溫高0.4 ℃耳溫約接近肛溫
Body temperature
• Definition: AM > 37.2 ℃ or PM > 37.7 ℃
• An increase in the hypothalamic set points
• Hyperpyrexia (高熱): > 41.5 ℃
– CNS related (ex: CNS hemorrhage)
– Severe infection
Fever
• Systemic inflammatory response syndrome
→ 兩項以上符合:
– Fever (oral >38°C) or hypothermia (<36°C)
– Tachypnea: >20 breaths/min or
PaCO2<32mmHg
– Tachycardia: >90 beats/min
– WBC > 12000 or <4000, or >10% bands
• Sepsis = SIRS + proven/suspected microbial
etiology
SIRS & sepsis
• Definitions
• Principles to approach fever or infection
• Introduction of antibiotics
• Prophylaxis
• Culture report
Contents
• History: TOCC and clinical symptoms
– Infection? Or fever with other causes
– Bacterial infection?
• The location of infection
• Community or hospital / healthcare
• Previous culture?
• Clinical condition: critical? Septic shock?
For new patients……
• Pneumonia
– CURB-65
– Clinical Pulmonary Infection Score (CPIS)
(> 6, suggestive of pneumonia)
• Infective endocarditis: Duke’s criteria
• Fungal infection: Candida score
Scorings or Criteria
• 重新評估病人可能發燒的原因→ History
taking + PE
• 最近的Blood culture或各種culture
→ 如果太久,應評估是否重新收culture
• 相關檢查:CXR、Urine routine、抽血等
• 評估是否給Antibiotics
• 症狀緩解
When you are on duty…
• Check cultures!
• Evaluate the clinical condition after 3 days
– Symptoms and signs
– Lab data: WBC, CRP, procalcitonin
(Do NOT recheck procalcitonin regularly)
– Recheck scorings (ex: CPIS)
– Ensure the culture data!
• The fewer antibiotics, the better!
When you start to use Abx,
• Adjust renal dose in IV form, except:
– Renal/biliary: ceftriaxone
– Biliary: tigecycline, metronidzone
– Metabolism: linezolid, moxifloxacin
• Monitor kidney and liver function
– Aminoglycosides, vancomycin
– Rifampin
Kidney and Liver
• Direct:
– GI disturbance, allergy, drug fever, etc.
– nephrotoxicity + ototoxicity (aminoglycosides), neurotoxicoty, cardiac toxicity (macrolides), bone marrow suppresion (linezolid)
– drug-drug interaction
• Indirect:
– change flora
– drug-resistant pathogens
Side effects
• According to clinical conditions and the
results of cultures!
• Empiric → definitive (narrow)
• IV form → oral form, except
– Infective endocarditis
– CNS infection
De-escalation of antibiotics
• Recheck the infection source and culture
• Clearing the source is better than only
antibiotics use!
If becoming worse, ……
• Acetaminophen
• Aspirin
• Nonsteroidal anti-inflammatory drugs
(NSAIDs): PGE2 inhibitors
• Glucocorticoids
• Paroxysmal sympathetic hyperactivity:
Morphine, beta-blockers, BZDs, etc.
Antipyretics
• Acetaminophen: impaired liver function if
4g/day (一天不超過八顆)
• Aspirin: Reye’s syndrome in children
• NSAIDs: GI bleeding, acute kidney injury,
poor-controlled hypertension
• Glucocorticoids: Immunosuppressive
Antipyretics: side effects
• Definitions
• Principles to approach fever or infection
• Introduction of antibiotics
• Prophylaxis
• Culture report
Contents
• Bactericidal drugs:
– death and disruption of the bacterial cell
• Bacteriostatic drugs:
– inhibit bacterial replication without killing
– rely on an intact immune system
– inhibits protein sunthesis
– Aminoglycosides, Macrolide, Tigecycline,
Linezolid
Bactericidal vs. Bacteriostatic
Pharmacodynamic properties
Parameter predicting
responseDrug or drug class
Time above the MIC Beta-lactams, aztreonam
24-h AUC/MIC
Aminoglycosides, fluoroquinolones,
macrolides, tigecycline, daptomycin,
vancomycin, etc.
Peak to MIC Aminoglycosides, fluoroquinolones
• Definitions
• Principles to approach fever or infection
• Introduction of antibiotics
• Prophylaxis
• Culture report
Contents
• Use Amoxicillin
• Patients who need antibiotics prophylaxis
– Prosthetic valves
– History of infective endocarditis
– Congenital cyanotic heart disease without
repair or residual defect after repair
Infective endocarditis
• Definitions
• Principles to approach fever or infection
• Introduction of antibiotics
• Prophylaxis
• Culture report
Contents
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Blood culture
Staphylococcus-like: S.aureus, CoNS ...
Streptococcus-like: Streptococcus, Enterococcus ...
GNB