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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1134_Библиотеки_им_академика_М_И_Перельмана.pdf
388
D.J. Mancini et al.
trauma patient is usually caused by dilution or administration
of large volumes of citrated pRBC. Calcium chloride, 1 g IV
for every four units of pRBC, or close monitoring of ionized
calcium levels aids in avoiding hypocalcemia and subsequent cardiac impairment. Refractory hypokalemia or hypocalcemia is often caused by hypomagnesemia. Magnesium
levels are monitored regularly and kept within a normal
range. Beware of repletion with oral magnesium formulations as these often lead to diarrhea. Adequate phosphate levels are essential for providing a substrate for ATP production.
Heightened awareness of phosphate levels around the time of
initiation of feeds and the need for replacement helps prevent
refeeding syndrome and hypophosphatemia [
50 ].
Gastrointestinal/Nutrition
Begin enteral nutrition as soon as possible in the ICU trauma
patient, ideally, within the fi rst 24–36 h [ 51 ]. Enteral nutri-
tion is the preferred method of delivery of nutritional support. TPN should be considered only in patients with a
long-term contraindication to the use of the gastrointestinal
tract for feeding. Critically ill trauma patients should receive
20–25 kcal/kg/day of nutrition. These patients are in a persistent elevated catabolic state with increased protein needs,
in the range of 1.5–2.0 g/kg/day of protein. Overfeeding
patients does not hasten their recovery but instead increases
their risk of complications. Weekly prealbumin, albumin,
and c-reactive protein (CRP) are helpful in following nutritional status. In pro-infl ammatory states, prealbumin needs
to be interpreted with caution. Prealbumin is an anti-acute
phase reactant and will be lowered in critically ill patients.
Measurement of the CRP allows for better interpretation of
prealbumin levels. If the CRP is normal, prealbumin is a
more accurate assessment of the patient’s nutritional state.
Gastrointestinal prophylaxis against mucosal stress ulceration in the form of H2 blocker is started in all intubated
patients. There is no benefi t to proton pump inhibitor therapy
over H2 blockers. Patients on either a proton pump inhibitor
or H2 blocker at home or on steroids in the hospital should
continue GI prophylaxis following extubation; all other
patients should have it discontinued [ 52 ].
Hematology
Deep venous thrombosis (DVT) and venous thromboembolism (VTE) is a major cause of morbidity and mortality for
the trauma patient. Several risk factors increase the risk of
DVT including spinal cord injury, long bone fractures in
severely injured patients, pelvic fractures, and GCS <8 and
age >50 years [ 40 ]. Weekly surveillance ultrasound for DVT
diagnosis increases the ability to detect asymptomatic DVT
but does not affect the ability to prevent pulmonary embolism [
40 ]. VTE prophylaxis is essential for every trauma
patient. LMWH is the preferred agent for chemoprophylaxis
in trauma patients [
because of weight, renal function, or injury, may be started
on subcutaneous heparin [SQH]. SQH is the agent of choice
in patients with intracranial bleeds. SQH as DVT prophylaxis
can safely be started in patients with intracranial bleed that
have demonstrated stability after 48 h [
In patients with documented DVT or PE, therapeutic anticoagulation is indicated. Anticoagulation with subcutaneous
LMWH gets patients to therapeutic levels of anticoagulation
faster than UFH. Tighter control of anticoagulation in the
patient at risk of bleeding or needing to have anticoagulation
held is possible with intravenous SQH. If a patient is not a
candidate for therapeutic anticoagulation, an inferior vena
cava (IVC) fi lter may be placed. Studies show no benefi t of
the combination of IVC fi lter and therapeutic anticoagulation for treatment of DVT or PE [ 55 ].
53 ]. Patients unable to take LMWH,
54 ].
Infectious Disease
Nearly a quarter of all in trauma patients will have some
form of infection following their injury [ 56 ]. Infections can
occur at the site of injury, secondary to surgery or as a healthcare acquired infection (HAI), with pneumonia being the
most common HAI in the trauma patient population.
Prevention, as in so many other areas, is essential.
Debridement of devitalized tissue and cleansing of traumatic
wounds and prompt removal of tubes, lines, and drains are
important aspects of infection prevention.
Antibiotic prophylaxis can be tailored to fi t an array of injury
patterns. In penetrating abdominal trauma, antibiotic prophylaxis should begin perioperatively and be completed by 24 h
postoperatively. Patients with open abdomens do not require
additional antibiotics aside from a single dose of an antibiotic
with gram-positive coverage at the time of reoperation.
Splenectomy requires vaccination against pneumococcus,
Haemophilus infl uenza , and Neisseria meningitidis at 2 weeks
postoperatively or prior to discharge from the hospital. No good
evidence exists, either for or against, antibiotic prophylaxis for
chest tube insertion. Prophylaxis is generally not indicated for
traumatic wounds unless associated with an open fracture.
Treatment of suspected or documented infections in
trauma patients follows the same principles as for other ICU
patients. Broad therapy is indicted for early severe infection
but should be narrowed as soon as possible based on culture
data. Duration of therapy must be tailored to location, organism, and response. Prevention of infection with handwashing, meticulous aseptic technique for procedures, and prompt
removal of indwelling devices remain paramount throughout
the patient’s hospital course.
33 Trauma
389
Endocrine
Glucose control in the trauma patient aids in the prevention
of secondary infection. Target glucose concentration is
≤150 mg/dL [ 56 ]. At this level of control, the risk of hypo-
glycemia is lessened and the same benefi t as tighter glucose
control is achieved. Avoidance of variability in serum glucose levels may be an important factor [ 57 ]. Insulin drips
offer the tightest control modality and can be used to calculate a daily total insulin requirement in patients on stable
nutritional regimen.
Adrenal insuffi ciency in critically ill trauma patients
remains in the differential diagnosis for refractory hypotension, fever, and hyponatremia. If adrenal insuffi ciency is suspected, a random cortisol may be sent and steroid
replacement, 50 mg hydrocortisone IV every 6 h, started.
Alternatively hydrocortisone may be started empirically on
any patient with escalating vasoactive support of blood pressure [ 24 ]. In these circumstances the hydrocortisone should
be continued until the vasoactive medications have been
weaned to off.
Musculoskeletal
In the trauma patient with multiple injuries, delayed diagnosis of fractures is possible. A thorough and complete tertiary
exam with judicious use of imaging can avoid missed fractures. Fracture management involves early restoration of
anatomy and function and alleviating pain. In the unstable
patient, this can be accomplished with traction or external
fi xation. Open fractures require operative washout and
debridement within 6 h, antibiotic coverage for 48 h after
defi nitive management and stabilization. Open fractures are
classifi ed based on the Gustilo and Anderson classifi cation
(Table 33.4 ) [ 28 ]. Type IIIb and IIIc fractures may require
external fi xation for stabilization, while type II and IIIa fractures can be treated with intramedullary nailing.
Pelvic fractures are frequently encountered in the ICU
trauma patient. Pelvic disruption can result in 3–4 L of blood
loss into the pelvis. Pelvic binding can reduce pelvic volume
and decrease bleeding. Binders do not provide mechanical
stability and should be taken down every 24 h to assess for
pressure necrosis. A blush, or active extravasation, seen on
CT scan is an indication for urgent angioembolization of the
bleeding vessel in the pelvis [ 58 ].
Long bone fractures to the femur and tibia are also frequently seen. Early operative reduction and internal fi xation
(ORIF) speeds the recovery of patients [
59 ]. If ORIF is
delayed because of the patient condition, traction should be
applied at the bedside. Knee dislocations have a high incidence of vascular injury to the popliteal artery. Knee
dislocations and tibial plateau fractures need to be closely
monitored for the possibility of compartment syndrome with
a low threshold for four-compartment fasciotomy [ 59 ].
Fractures of the long bones or pelvis are associated with
fat emboli syndrome. Fat emboli syndrome manifests as
respiratory distress, altered mental status, and petechial rash
41 ]. Fat emboli may occur at the time of injury or during
[
surgical repair of the fractures. The diagnosis is one of exclusion, care is generally supportive, and prognosis for recovery
is excellent.
Tubes/Lines and Drains
During the trauma patient’s stay in the ICU, particular attention should be paid to tubes, lines, and drains. The guiding
principle is to remove any invasive line, central venous catheter, or arterial line, as soon as no longer needed. Intravenous
lines placed emergently in the trauma bay should be removed
promptly and new access obtained under sterile conditions.
Close coordination with the surgical team on management of
chest tubes and suction drains is helpful. Chest tubes can
often rapidly be progressed to water seal and removed once
the output is less than 200 mL a day. The original indication
for placement and amount and quality of drainage from
intra-abdominal drains needs to be considered prior to their
removal. Subcutaneous drains are usually able to be removed
once the output is less than 25 mL a day for two consecutive
24 h periods. Urinary catheters are usually removed within
48 h, unless there is an indication for continuous bladder
drainage. In patients with genitourinary injuries, the catheter
is maintained for longer, and discussion of timing of removal
should occur between the ICU, trauma, and consultant teams.
Table 33.4 Gustilo and Anderson classifi cation of open fractures
Type I: low energy, <1 cm wound caused by protrusion of bone or
lowed velocity gunshot wound
Type II: moderate energy, >1 cm with fl ap or avulsion wound in the
skin with minimal devitalized soft tissue and minimal contamination
Type III: high energy, extensive soft tissue injury
Type IIIa: adequate soft tissue coverage, no vascular injury
Type IIIb: signifi cant soft tissue loss with exposed bone that
requires tissue transfer for coverage
Type IIIc: vascular injury requiring repair for limb preservation
Special Considerations
Damage Control Abdomen
Open abdomen with VAC dressing or other form of abdominal coverage is often encountered as part of damage control
procedures. The physiologic state of the patient or overall
burden of injury precludes closure at the fi rst operation.
390
D.J. Mancini et al.
Patients are brought to the ICU for further resuscitation and
correction of hypothermia and prevention of coagulopathy.
After the fi rst operation, patients may be left in discontinuity
or have laparotomy pads remaining in the abdomen. In these
cases the patient should return to the OR for a second operation within 24 h [ 60 ]. In all cases patients should return to the
OR every 48 h until the abdomen is closed [
61 ]. Ideally the
fascia is closed by the third operation to avoid complications
of the open abdomen [ 61 ]. Dynamic fascial closure tech-
niques and optimization of fl uid balance with diuresis as tolerated has been shown to improve the likelihood of fascial
closure [ 62 ].
Transport
Transportation of the ICU trauma patient off of the unit for
procedures or studies is a frequent occurrence and one that
can be dangerous. Suffi cient staff to travel with the patient
and robust monitoring during transport can minimize mishaps. Every transport out of the ICU should be assessed from
a risk benefi t standpoint.
ICU as an OR
Clinical circumstances may dictate that movement of a
patient out of the ICU is not feasible. In these cases the ICU
can function as an operating room. Laparotomy or removal
of a VAC dressing, although more optimally performed in
the operating room, may be undertaken in the ICU. An
already prepared set of separate supplies facilitates the performance of these urgent procedures. More routine procedures such as percutaneous tracheostomy or endoscopic
gastrostomy tube placement may also be performed in the
ICU. Again adequate preplanning and equipment are essential for successful completion of any procedure in the ICU.
Family Support/Interaction
It is essential to establish early contact with family members,
to fully explain injuries, clinical condition, and prognosis.
Open communication provides family members with essential information and establishes a relationship between the
ICU care team and the family. Administrative facts, such as
ICU procedures, visiting hours, and available services,
should also be explained. Locating a living or identifying a
healthcare proxy will help guide management decisions,
especially in the elderly trauma patient. In the later stages of
ICU care, the patient and family are prepared for the transition to a non-ICU environment.
End of Life/Gift of Life
The constellation of a trauma patient’s injuries and complications may be nonsurvivable. A prior well-established relationship with the patient and the family facilitates effective
communication at the end of life. This period of the patient’s
care can be highly emotional for family and staff and may be
fraught with confl ict. Involvement of a palliative care team
can be benefi cial. Palliative care should be engaged early
with patients with severe injuries as the focus on alleviation
of suffering for the patient, and support for the family can be
utilized throughout the different phases of ICU care.
Discussion of end of life care in the ICU is intertwined
with discussions about organ donation. Every patient who
dies in the ICU should be afforded the opportunity to be an
organ donor. The ICU team should never initiate discussion
of donation with a patient’s family and friends. When a
patient has been identifi ed as a potential donor, contact with
the regional organ donation network allows for better coordination of care as well as discussion with family and loved
ones about the donation.
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Immunocompromised Patients
Judith Anesi and Valerianna Amorosa
3 4
Introduction
In this chapter, we will discuss the care of the
immunocompromised patient in the surgical ICU. We will
specifi cally review the care of patients who have undergone
solid organ transplantation (SOT), stem cell transplantation
(SCT), chemotherapy, radiation, chronic corticosteroid
therapy, and TNF-α (alpha) inhibitor therapy, as well as the
care of patients with HIV/AIDS, chronic hepatitis B virus
(HBV), or chronic hepatitis C virus (HCV) infection. These
patient populations are among the most profoundly
immunocompromised, but it is important to understand that
immunosuppression is a spectrum and that patients who do
not fall into one of these specifi c populations may still be
signifi cantly immunocompromised, such as patients with
diabetes mellitus, chronic kidney disease, or cirrhosis.
Unfortunately, there is no measure of degree of immunosuppression or risk of infection, so it is impossible to determine
exactly where on the spectrum each patient resides. Studies
of the special patient populations that we will address, however, give some insight into the infectious risks of those who
are immunosuppressed and can be used to guide the approach
to all patients with immunosuppressing conditions.
There are several general principles that apply to the man-
agement of all immunocompromised patients:
• Patients who are immunosuppressed may not present with
classic symptoms of an infection and may in fact have
more vague or mild symptoms than usual due to an inability to mount an infl ammatory response [
immunocompromised patients with a bowel perforation
J. Anesi , MD (*)
Department of Medicine , Hospital of the University of Pennsylvania ,
Philadelphia , PA 19104 , USA
Judith.anesi@uphs.upenn.edu
e-mail:
V. Amorosa , MD
Department of Medicine , Perelman School of Medicine,
University of Pennsylvania , Philadelphia , PA 19104 , USA
1 ]. For example,
may not have signifi cant abdominal pain or peritonitis on
exam.
• Due to the subtlety of their clinical presentations when an
infection is present, any abnormality in an immunocompromised host should be closely scrutinized. In particular,
close attention should be paid to examining the skin,
mucosa, lymph nodes, catheter entry sites, surgical incisions/wounds, subtle neurologic fi ndings, and any bony/
joint abnormalities in these patients.
• Our approach to the initial diagnostic evaluation for infection in immunocompromised hosts is summarized in
Table 34.1 . As infection can progress more rapidly in
these patients, early and aggressive pursuit of a microbiologic diagnosis is critical, and invasive diagnostic procedures are often necessary. Refer to the specifi c sections on
SOT, SCT/chemotherapy, chronic corticosteroid therapy,
TNF-α (alpha) inhibitor therapy, HIV/AIDS, and chronic
HBV/HCV for further details on our approach to diagnostic evaluation in these populations.
• Infection is not the only cause of fever in immunocompromised patients in the surgical ICU. Other common
causes of fever that should also be considered include
thrombosis, bleeding, and drug fever, and, in the case of
SOT or SCT recipients, allograft rejection and graftversus- host disease (GVHD).
• Early antibiotic administration in critically ill patients has
been shown to confer a survival benefi t, so early initiation of
broad-spectrum antibiotics in these patients is critical [ 2 , 3 ].
After 48 h of diagnostic and supportive care, however, antibiotics should be revisited and narrowed as appropriate.
• When an infection is diagnosed, immunosuppression should
be reduced to the lowest acceptable level (except in the rare
circumstance of a central nervous system infection, where
reduction in immunosuppression can result in immune
reconstitution infl ammatory syndrome that may be dangerous due to a resultant increase in the intracranial pressure).
• Due to the complexity of these patient populations, when
an infection is suspected, infectious disease specialists
should be involved to help comanage these patients.
© Springer International Publishing Switzerland 2016
N.D. Martin, L.J. Kaplan (eds.), Principles of Adult Surgical Critical Care, DOI 10.1007/978-3-319-33341-0_34
393
394
J. Anesi and V. Amorosa
Table 34.1 Initial diagnostic evaluation for immunocompromised
hosts in the ICU
Symptoms Initial evaluation steps
Fever Two sets of blood cx, urinalysis and urine
cx, CXR PA and lateral; further
investigation based on localizing signs and
symptoms
Respiratory symptoms CXR PA and lateral
Sputum sample for gram stain, cx
(including Legionella cx), ± PCP stain
Legionella urinary Ag, S. pneumoniae Ag
Respiratory virus PCR panel including
human metapneumovirus
Cavitating/nodular lesions: sputum for
AFB stain, mycobacterial cx, fungal stain
and cx; serum galactomannan, β-D-glucan,
cryptococcal antigen, urinary Histoplasma
antigen → early bronchoscopy
Urinary symptoms Urinalysis and urine cx
Renal graft ultrasound if renal transplant
recipient
Hematuria: BK virus PCR on blood,
adenovirus PCR on urine
Diarrhea
Skin rash Vesicular: HSV/VZV PCR
Headache, altered
mental status
Leukopenia CMV PCR, EBV PCR, parvovirus PCR
New anemia Parvovirus PCR
Abbreviations : AFB acid fast bacilli, Ag antigen, C diff Clostridium dif-
fi cile , CSF cerebrospinal fl uid, CT computerized tomography, CXR
chest x-ray, cx culture, EBV Epstein-Barr virus, HSV/VZV herpes sim-
plex virus/varicella zoster virus, LP lumbar puncture, O+P ova and
parasite, PA posterior-anterior, PCP Pneumocystis jiroveci , PCR
merase chain reaction
Stool cx, C diff toxin, O+P, adenovirus
stool cx, rotavirus Ag, norovirus PCR
Target lesion: Lyme antibody
Pustular: gram stain and cx
Necrotic, petechial, any other description:
skin biopsy and culture
CT head
LP with opening pressure; CSF cell count,
glucose, total protein, cytology, gram stain,
cx, cryptococcal Ag (blood and CSF),
HSV PCR, VZV PCR (hold extra CSF)
May–Nov: CSF for enterovirus PCR
Consider urine adenovirus PCR
In spring/summer: peripheral smear for
Babesia , Ehrlichia , Anaplasma if in
endemic region
In spring/summer: peripheral smear for
Babesia , Ehrlichia , Anaplasma if in
endemic region
poly-
Solid Organ Transplant Recipients
Overview of Infectious Risks and Initial Diagnostic Evaluation
The infectious risks for SOT recipients vary over time
posttransplant. In the fi rst month after transplantation, most
infections are due to (1) nosocomial infections, such as
aspiration pneumonia, ventilator-associated pneumonia,
catheter- related bloodstream infection, catheter-related urinary tract infection, and Clostridium diffi cile , or (2) surgical
complications, including wound infections, anastomotic leaks,
or ischemia of the allograft [
1 ]. SOT recipients are at increased
risk for developing these infectious syndromes with
multidrug- resistant organisms, including methicillin- resistant
Staphylococcus aureus (MRSA), vancomycin- resistant
Enterococcus species (VRE), multidrug-resistant (MDR)
gram-negative rods (GNRs), or azole-resistant Candida spe-
cies, in part due to their hospital exposure [
1 ]. Two other
important sources of infection in the fi rst month post-SOT are
(1) infection or colonization of the recipient that was untreated
prior to transplantation and (2) donor- derived infections. The
recipient may be the source if there was unnoticed viremia
(with HIV, hepatitis B, or hepatitis C), bacteremia, or fungemia at the time of transplant; latent infection with
Mycobacterium tuberculosis (TB), Strongyloides , and
Trypanosoma cruzi that reactivates post- SOT; or colonization
with Aspergillus or Pseudomonas (particularly of the lungs)
that caused infection posttransplantation [ 4 – 10 ]. Donor-
derived infections are typically due to unnoticed active infection of the allograft with bacteria or fungus at the time of
transplantation [ 11 – 13 ]. More rarely, recipients can contract
viral or parasitic infections via the donor, including herpes
simplex virus (HSV), lymphocytic choriomeningitis virus
(LCMV), rabies, West Nile virus, HIV, hepatitis B, hepatitis C,
T. cruzi , or Strongyloides [ 14 – 19 ]. Patients rarely develop
opportunistic infections (such as Pneumocystis jiroveci (PCP)
or cytomegalovirus (CMV)) during this fi rst month post-SOT.
The initial diagnostic evaluation and management of SOT
recipients who are <1 month posttransplantation and have a
suspected infection should include removing all vascular and
urinary catheters, closely examining all wounds and drain
outputs for signs of infection, culturing the blood and urine,
obtaining a two-view chest x-ray, checking for C. diffi cile ,
and imaging of the allograft. The pretransplantation cultures
from both the donor and recipient should be reviewed to
ensure that the recipient was adequately treated for any
organisms that grew on those cultures perioperatively. If the
patient does not improve after this standard approach, rare
donor-derived infections (such as HSV, LCMV, West Nile,
rabies, HIV, hepatitis B, hepatitis C, and T. cruzi ) should be
considered as well.
When SOT recipients are between 1 and 6 months posttransplantation, opportunistic infections and reactivation of
latent infections become more common due to the accumulated immunosuppression over the prior months. Prior to the
widespread use of PCP and CMV prophylaxis, these organisms typically caused infection during this time period. If a
SOT recipient is receiving prophylaxis, however, infection
with these organisms is rare [
20 ]. If prophylaxis has been
stopped for any reason, then PCP and CMV diseases should
be considered [
1 , 21 ]. PCP typically presents with fever and
34 Immunocompromised Patients
395
respiratory symptoms including cough, shortness of breath,
and hypoxia [
22 ]. A chest x-ray may be unremarkable with
PCP infection, but chest CT typically shows ground-glass
opacities (though there is no specifi c radiographic pattern
that is pathognomonic) [ 23 ]. CMV syndrome typically pres-
ents with fatigue and malaise along with leukopenia and/or
thrombocytopenia, but it can also cause tissue-invasive disease of nearly any organ including pneumonitis, colitis, hepatitis, nephritis, myocarditis, pancreatitis, and retinitis [ 24 ,
25 ]. CMV disease can also be associated with allograft dys-
function and rejection [ 26 ]. Those at highest risk of develop-
ing CMV disease are donor/recipient pairs in which the
donor was CMV seropositive and the recipient was CMV
seronegative prior to transplantation [ 27 ]. Of note, CMV
prophylaxis also prevents reactivation of other herpesviruses,
so if CMV prophylaxis is held, HSV, VZV, and Epstein-Barr
virus (EBV) can also reactivate and cause disease. Fungal
opportunistic infections can also present during this time
frame, including aspergillosis (most commonly with pneumonia) and cryptococcosis (most commonly with meningitis
or pneumonia), though most fungal infections occur after
6 months post-SOT [ 28 ]. Latent infections can also reacti-
vate and/or disseminate during this time period, including
endemic fungi ( Histoplasma , Coccidioides , Paracoccidioides ,
and less frequently Blastomyces ), TB, Strongyloides , T.
cruzi , BK virus, adenovirus, and hepatitis B (if no antiviral
prophylaxis is employed).
The diagnostic evaluation for patients who are between 1
and 6 months post-SOT depends on the clinical presentation,
though all such patients should have two sets of blood cultures, a urinalysis, a urine culture, and a two-view chest x-ray
performed. Of note, if a patient remains hospitalized for a
prolonged period after transplantation or has repeated surgical procedures posttransplant, the early nosocomial or surgical sources of infection may remain relevant as well.
Abdominal imaging, typically with a CT scan, should
also be considered to evaluate for abdominal abscess. If
the patient has had relevant exposures, such as travel to a
tropical region, then Strongyloides should be evaluated
for with a stool sample examination for ova and parasites
and a Strongyloides serum antibody (though serologies
can be less reliable post-SOT).
• Headache, neck stiffness, and altered mental status: An
urgent lumbar puncture should be performed, and the
CSF should be sent for cell counts, glucose, total protein,
gram stain, culture, as well as cryptococcal antigen, fungal culture, mycobacterial culture, and HSV PCR. Extra
CSF should be held in case further testing is needed, e.g.,
for VZV PCR, enterovirus PCR, or West Nile Ab testing.
Head imaging, typically magnetic resonance imaging
(MRI), should also be considered to exclude any mass
lesions, and depending on the clinical scenario, CT scan
prior to lumbar puncture may be appropriate to assess for
cerebral edema or a mass lesion.
• Hematuria: In addition to a urinalysis and urine culture, a
BK virus PCR from blood and adenovirus PCR from
urine should be considered.
• Skin lesions: In general, any SOT recipient with a new
rash should be evaluated by dermatology for a skin biopsy
with culture, since bacterial, fungal, and viral pathogens
can occasionally present fi rst with skin manifestations
when there is an underlying disseminated infection. If the
lesions are vesicular, a lesion should be unroofed and sent
for HSV/VZV PCR.
• Leukopenia and/or thrombocytopenia: Consider checking a CMV PCR, EBV PCR, and parvovirus PCR from
blood, as well as evaluating for tick-borne diseases (with
Lyme antibody and a blood smear for Babesia , Ehrlichia ,
and Anaplasma ) if the patient resides in an endemic
region.
• Respiratory symptoms: A chest x-ray, sputum culture,
and respiratory virus polymerase chain reaction (PCR)
panel should be obtained immediately, followed by chest
computerized tomography (CT) and bronchoscopy if any
abnormalities are found on the initial workup.
Bronchoscopy specimens should be evaluated by direct
microscopy (for PCP primarily), gram stain, and culture
including fungal and mycobacterial culture. If there is
suspicion for a fungal infection (e.g., nodular opacities on
chest CT), then serum galactomannan, β-D-glucan, cryp-
tococcal antigen, and urinary Histoplasma antigen can be
considered as well. Of note, there are signifi cant limitations to the utility of the galactomannan and β-D-glucan
assays in the SOT population, both in terms of sensitivity
and specifi city, and should not be solely relied upon for
making the diagnosis of a fungal infection [ 29 , 30 ].
• Abdominal pain, vomiting, and diarrhea: A stool sample
should be evaluated for ova and parasites (including
Microsporidia and Cyclospora ), culture, and C. diffi cile .
When an SOT recipient is more than 6 months posttransplantation, the overall risk of infection decreases since
immunosuppression is typically tapered over this time [ 1 ].
Patients do remain at increased risk for community-acquired
infections, however, including community-acquired pneumonia, respiratory viral infections, and urinary tract infections. Although fungal infections can present earlier, they are
more common during this time period (including Aspergillus
and other mold infections), as are opportunistic bacterial
infections such as Nocardia and Rhodococcus (which all
predominantly present with respiratory symptoms and cause
pulmonary infections) [ 28 ]. If CMV or PCP prophylaxis is
stopped during this period, then CMV, other herpesviruses,
and PCP can present at this time. The initial diagnostic evaluation of patients who are >6 months post-SOT should be
largely similar to that for patients who are 1–6 months postSOT, and we would recommend using the same approach
(that is described above) based on the patient’s presenting
symptoms.
396
J. Anesi and V. Amorosa
Empiric Therapy
Empiric therapy will depend on the patient’s presenting
symptoms, but in general, when a SOT recipient presents
with an infectious syndrome, broad-spectrum antibiotics
(and in some cases antifungals) are used initially and then
narrowed based on the results of the diagnostic evaluation. It
is of the utmost importance to collect cultures before beginning antibiotics as even one dose of antibiotics can make it
diffi cult to establish a diagnosis. In general, it is recommended to start with an agent that covers gram-positive
organisms including MRSA (such as vancomycin, linezolid,
or daptomycin) and an agent that covers gram-negative
organisms including Pseudomonas (such as cefepime or
piperacillin-tazobactam). If the patient has a history of infection with drug-resistant organisms, those organisms should
be covered as well (e.g., if the patient has a history of VRE,
linezolid is preferable to vancomycin, or if a patient has a
history of an MDR GNR, a carbapenem is preferable to
cefepime or piperacillin-tazobactam). Examples of appropriate empiric regimens are given in Table 34.2 ; of note, these
regimens are appropriate for patients admitted to a surgical
ICU and may not be appropriate for patients who are less ill
and not in the ICU.
Table 34.2 Empiric antimicrobial therapy for SOT recipients admitted
to the ICU
Time post-SOT Empiric antimicrobial therapy
<1 month Vancomycin plus [cefepime or
piperacillin-tazobactam]
Ensure donor and recipient prior culture growth
is covered
If diarrhea present, consider PO vancomycin
If infl uenza season, add oseltamivir
If PNA symptoms, add azithromycin
If recent abdominal surgery or on chronic TPN,
consider antifungal (echinocandin or fl uconazole)
Would not empirically treat CMV or mold
>1 month Vancomycin plus [cefepime or
piperacillin-tazobactam]
Ensure donor and recipient prior culture growth
is covered
If diarrhea present, consider PO vancomycin
If infl uenza season, add oseltamivir
If PNA symptoms, add azithromycin
If PNA symptoms and not on PCP ppx, consider
adding trimethoprim/sulfamethoxazole and
prednisone
If recent abdominal surgery or on chronic TPN,
consider antifungal (echinocandin or fl uconazole)
Would not empirically treat CMV, Aspergillus ,
other molds
Abbreviations : CMV cytomegalovirus, ICU intensive care unit, PCP P.
jiroveci , PNA pneumonia, PO oral, SOT solid organ transplantation,
TPN total parenteral nutrition
Chemotherapy, Radiation, and Stem Cell Transplant Recipients
Among patients who have received treatment for malignancy, there is a wide spectrum of immunosuppression and
risk for infection. The presence of cancer itself is likely
immunosuppressing, and the treatment of the malignancy
contributes further to a patient’s immunosuppression [
31 ].
Patients with solid tumors (e.g., breast cancer, colon cancer)
who have been treated with surgery, radiation, and/or chemotherapy are considered less immunocompromised than those
who have a hematologic malignancy (lymphoma, leukemia),
since the degree and duration of neutropenia are typically
much greater in those with a hematologic malignancy.
Patients with a solid tumor who are not neutropenic should
be approached similarly to the normal host, except that specifi c attention should be paid to the location of the tumor
when looking for a source of infection, as his/her anatomy is
often disrupted in that area, due to the tumor itself, surgery to
remove the tumor, or radiation that may have occurred there.
In patients who have undergone radiation, tissue destruction
causes chronic dysfunction of the venous and lymphatic
drainage in the region, which puts them at risk for infection
at the site of the prior radiation [ 32 , 33 ]. Part of the initial
evaluation for infection should include examination and
imaging of the radiation fi eld.
Patients with a solid malignancy who are neutropenic due
to chemotherapy and those with a hematologic malignancy
should be approached somewhat differently than the normal
host when infection is suspected, due to their increased
degree of immunosuppression. The patients considered most
immunosuppressed with the highest risk for infection are
those with a hematologic malignancy who have undergone
chemotherapy as well as SCT. We will review in detail now
the approach to patients who are neutropenic and those who
have undergone stem cell transplantation.
Neutropenic Patients
Overview of Infectious Risks
Patients who are neutropenic due to either a hematologic
malignancy or chemotherapy are at increased risk for infection. Neutropenia in this setting is defi ned as an absolute
neutrophil count (ANC) less than 500 cells/microliter (mL)
(where the ANC is equal to the total WBC count multiplied
by the percentage of neutrophils). Though all patients with
an ANC <500 cells/mL are at risk for infection, those who
are expected to have neutropenia for <7 days are generally
considered lower risk; most patients with solid tumors fall
into this group [ 34 ]. Patients who are expected to have neu-
tropenia for >7 days or who have evidence of hepatic or renal
dysfunction in addition to neutropenia are considered at
34 Immunocompromised Patients
397
higher risk [ 34 ]. When evaluating neutropenic fever, a fever
is defi ned as a single temperature ≥38.3 °C (101 °F) or a
temperature ≥38.0 °C (100.4 °F) sustained for over an hour.
Though 10–50 % of patients with solid tumors and over
80 % of patients with hematologic malignancies will develop
fever during an episode of neutropenia, most (70–80 %)
never have a specifi c source of fever identifi ed during the
diagnostic evaluation [
fi ed, the majority of infections are due to endogenous fl ora.
Coagulase-negative staphylococci are the most commonly
isolated organisms from bloodstream isolates, which is
thought to be due to the high prevalence of indwelling venous
catheters in this population [ 36 ]. There has, however, been
an increase in the number of drug-resistant gram-negative
bacteria observed as the source of infection in these patients
over the last several years [ 37 , 38 ].
During the fi rst week of neutropenia, most infections are
caused by bacterial pathogens. After 7 days of neutropenia,
fungal etiologies are possible, predominantly with Candida
species. Candidiasis in these patients is typically due to
mucosal infection (e.g., thrush) followed by mucosal breakdown that results in candidemia [ 39 ]. After about 10–15 days
of neutropenia, molds such as Aspergillus become more
common; they are rarely involved prior to 10–14 days of
neutropenia [ 40 , 41 ]. Aspergillosis predominantly causes
sinus or pulmonary disease in these patients.
35 ]. When a specifi c source is identi-
Initial Diagnostic Evaluation
When a patient with neutropenia develops a fever, at least two
sets of blood cultures should be drawn, along with a urinalysis, a urine culture, and a two-view chest x-ray. If the patient
has abdominal symptoms, a CT of the abdomen/pelvis is recommended to evaluate for neutropenic enterocolitis (or typhlitis) or intra-abdominal abscess, as well as a stool C. diffi cile
assay. If there are pulmonary symptoms, then a respiratory
virus PCR panel should be sent along with sputum culture. It
is also reasonable to consider a CT scan of the chest to evaluate for possible pulmonary fungal infection, as this typically
presents with small nodular lesions that may be diffi cult to
appreciate on chest x-ray. A CT of the chest to evaluate for
fungal infection is also reasonable in neutropenic patients
who have been febrile with no clear etiology for more than
4–7 days despite antibiotic therapy, again to look for a fungal
process. In those cases where fungal infection is suspected, it
is also appropriate to check serum galactomannan and β-D-
glucan assays, which are antigen tests for fungal infections.
The galactomannan assay is specifi c for Aspergillus , while
the β-D-glucan assay can be positive in the setting of Candida ,
Aspergillus , Pneumocystis , and Fusarium infection [ 42 – 44 ].
If a patient has been neutropenic for over 2 weeks and reports
any sinus symptoms, then a CT of the face and endoscopic
evaluation of the sinuses should be pursued to evaluate for a
fungal sinus infection, including mucormycosis.
Empiric Therapy
Neutropenic fever is a medical emergency due to the rapid
progression of infection seen in these patients. Initial antibiotic therapy should include at least an antipseudomonal
β-lactam, such as cefepime or piperacillin-tazobactam, which
should be initiated within 2 h of symptoms [
Pseudomonal coverage is recommended due to the high mortality associated with pseudomonal infections among neutropenic patients. In the setting of a penicillin allergy, aztreonam
can be substituted often alongside an antipseudomonal aminoglycoside such as tobramycin. Gram-positive coverage is
not a routine piece of empiric therapy, unless there is specifi c
concern for catheter-related bloodstream infection, skin/soft
tissue infection, or pneumonia. In cases where gram-positive
coverage is needed, vancomycin, linezolid, or daptomycin
can be added (to include MRSA coverage). The patient’s
prior cultures should also be reviewed to ensure there is not a
history of drug-resistant organisms, for example, VRE or
MDR GNRs; if a history of resistant organisms is found, the
initial antibiotic therapy should cover those MDR organisms
as well. If a patient has been neutropenic and febrile for more
than 4–7 days despite antibiotic therapy, then consideration
should be given to adding an antifungal agent with Aspergillus
coverage (an echinocandin or voriconazole) [
48 ].
45 – 47 ].
Stem Cell Transplantation Recipients
Overview of Infectious Risks and Initial Diagnostic Evaluation
The infectious complications after SCT vary over time
posttransplantation. At all time points, however, SCT
recipients are more likely to develop infection if they are
older, underwent allogeneic SCT, underwent myeloablative
conditioning (as opposed to reduced intensity chemotherapy), had an unrelated or mismatched donor at transplantation, underwent T-cell depletion, have graft failure, or have
developed GVHD [
During the fi rst 30 days post-SCT, before the donor stem
cells have engrafted and repopulated the immune system (the
“pre-engraftment” period), patients are neutropenic and suffer from similar complications as described above for other
neutropenic patients. Many will develop fevers during neutropenia, with similar etiologies as above. The diagnostic
evaluation should follow the recommendations given for all
neutropenic patients.
Following engraftment, from about day 30 through day
100 post-SCT (the “early post-engraftment” period), patients
become at risk for opportunistic infections. The major risk
factors for infection during this period include GVHD (and
its treatment), residual mucositis, and any ongoing neutropenia. The infections to consider during this time period depend
on the presenting symptoms:
49 ].