Infectiontreatment Treatment

• Change cannula sites if necessary

• Appropriate antibiotic therapy after laboratory specimens taken — though this may not be necessary for mild infections where the cause has been removed, e.g. an infected catheter

• Radiological and/or surgical intervention if indicated

Regular input from microbiological ± infectious disease specialists isrecommended to advise on best options for empiric therapy and for possible modifications based on early communication of laboratory results (including antibiotic sensitivity patterns).

Empiric antibiotic therapy is guided on the severity of illness of the patient, likely site of infection and likely infecting organism(s), whether the infection is community-acquired or nosocomial (including ICU-acquired), patient immunosuppression, and known antibiotic resistance patterns of hospital and local community organisms. In general, critically ill patients should receive parenteral antibiotics at appropriate dosage, taking into account any impaired hepatic or renal clearance, or concurrent renal replacement therapy. Broad-spectrum therapy may be initially needed, with refinement, cessation or change after 2-3 days depending on clinical response and organisms subsequently isolated. The duration of treatment remains highly contentious. Apart from specific conditions such as endocarditis, tuberculosis and meningitis, where prolonged therapy is probably advisable, it may be sufficient to stop within 3-5 days provided the patient has shown adequate signs of recovery. Alternatively, patients not responding or deteriorating should be considered to be either treatment failures or inappropriately treated (i.e. no infection was present in the first place).As described earlier, commonly accepted markers of infection are poorly specific in the intensive care patient. Indeed, pyrexia may settle on stopping antibiotic treatment. Cessation or change of antibiotic therapy must be considered on individual merits according to the patient's condition and any subsequent laboratory results. An advantage of ceasing therapy is the ability to take further specimens for culture in an antibiotic-free environment.

It may be necessary to remove indwelling pacemakers, tunnelled vascular catheters, prosthetic joints, plates, implants, grafts and stents if these are the suspected cause of infection. This should be done in consultation with microbiologists and the appropriate specialist as individual risk and benefit needs to be carefully weighed up.

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