Infectious disease clinics of North America
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Fever is a normal adaptive brain response to infectious and noninfectious causes involving a cytokine-mediated response, the generation of acute phase reactants, and the activation of numerous physiologic, endocrinologic and immunologic systems. Ninety percent of patients with severe sepsis in the intensive care unit (ICU) will experience fever during their hospitalization, while the half of the new detected febrile episodes are of noninfectious origin. In the ICU, fever should be treated in cardiorespiratory and neurosurgical patients and in those in whom temperature exceeds 40 degrees C (104 degrees F). Antipyretic therapy must be justified regardless of the metabolic cost (if fever exceeds its physiologic benefit), the result (if the symptomatic relief adversely affects the course of the febrile illness) and the side effects.
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Hospital-acquired infections have profound social, economic, and personal costs to patients in the intensive care unit (ICU). Numerous risk factors, such as poor nutrition and hyperglycemia, directly involve patients. ⋯ Infection-control committees can assist in implementing policies. This is an active area of research and we anticipate continued advancements to improve patient care.
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Infect. Dis. Clin. North Am. · Sep 2009
ReviewApproach to the immunocompromised host with infection in the intensive care unit.
Despite significant advances in the prevention, diagnosis, and treatment of infection in the immunocompromised host, it remains a major cause of morbidity, increased length of stay, total costs, and of course mortality. Intensive care mortality rates are significantly higher among immunocompromised hosts in part due to the higher incidence of infection severity. The superimposition of the compromised host defenses and critical illness makes the detection and management of infections in such patients more difficult, but crucial toward salvaging patient outcome. Moreover, although there is a rapidly increasing evidence base in intensive care medicine, many interventional trials for the management of severe sepsis (activated protein C, adjunctive corticosteroids, goal-based resuscitation), acute lung injury (low stretch ventilation), and other organ failures have excluded immunocompromised hosts.
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Pulmonologists and intensivists often care for patients at risk for infections caused by both Aspergillus and Candida. Infection with either can lead to severe life-threatening disease, particularly in immunosuppressed patients, with mortality rates for invasive fungal disease often exceeding 30%. ⋯ Fortunately, therapeutic paradigms are shifting, and clinicians have many new agents in their armamentarium for combating fungal infection. Given the rapidly changing literature in this broad area, it is imperative that physicians caring for immunosuppressed patients and for the critically ill remain abreast of this evolving field.
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Ventilator-associated pneumonia (VAP) management depends on the interaction between the infective agent, the host response, and the antimicrobial drug used. After the pathogen reaches the lungs, two outcomes are possible: either the microorganisms are eliminated by the host immune system, or they overcome the immune system and cause pulmonary infection. ⋯ The daily management of VAP remains a challenge for physicians in the ICU. In recent years, a more dynamic approach has evolved, updating local epidemiology, evaluating VAP and diagnostic tools every day, and assessing host response using clinical and biochemical parameters.