Approach to the Immunocompromised Host with Infection in the Intensive Care Unit

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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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Altered Clinical Expression

Because of diminished or absent inflammatory responses, the expected local clinical and radiographic signs of infection may not be present. In patients who are critically ill there are other confounders which may camouflage symptom and sign detection, such as iatrogenic sedation, and multiple processes (fluid overload, atelectasis), which produce pulmonary radiographic changes unrelated to infection. Detectable but atypical presentations caused by opportunistic pathogens are also more prevalent

Initial assessment of the immunocompromised patient

A pathogen-based discussion does not accurately emulate real clinical practice where the clinician initially only has knowledge of the type of immune defects and the patient's signs and symptoms suggestive of infection. There is a common ethic to the diagnostic assessment of the diverse population who meet the definition of immunocompromised host. The specific types of natural or acquired immune compromise predisposes such hosts to infection with a spectrum of pathogens which can be further

Common clinical presentations

Although there is a diverse number of opportunistic pathogens which may cause invasive disease in the immunocompromised host, there are a finite number of stereotypical presentations or syndromes (Box 3). Systemic signs of infection coupled with respiratory insufficiency/failure and radiographic infiltrates, altered sensorium with or without focal neurologic signs and fever/sepsis of unknown origin are two characteristic presentations which usually culminate in ICU admission and merit

Management of iatrogenic immunosuppression

Withdrawal or rapid tapering of iatrogenic immunosuppression, particularly corticosteroids, is a well-described option particularly in organ transplant recipients with rapid deterioration caused by life-threatening infection or posttransplant lymphoproliferative disease.56, 57 However there are several mitigating factors which need to be considered on a case-by-case basis:

  • Is allograft rejection already occurring? Unexplained allograft dysfunction should be investigated with a biopsy to rule out

Protective isolation and special precautions

Despite the higher prevalence of multidrug resistant bacteria in the ICU, more severe illness of the immunocompromised host requiring ICU care, the vast majority of immunocompromised hosts requiring intensive care do not routinely require protective or reverse isolation. The intent of protective isolation is to prevent the acquisition of exogenous organisms by maintaining them in a single room, with a closed door to limit entry, coupled with ambient positive pressure. Such practices have

Emerging trends among immunocompromised hosts relevant to ICU practice

Multidrug-resistant bacteria, particularly from the nosocomial setting, have become more prevalent among immunocompromised hosts because of their greater time exposure to the health-care environment and selective pressure from prophylactic and therapeutic anti-infective exposure. Since the 1990s, VRE has become a prominent pathogen in oncologic and liver-transplant recipients although its clinical impact has diminished somewhat with the use of linezolid therapy. Early reports of

References (67)

  • K.A. Marr et al.

    Prolonged fluconazole prophylaxis is associated with persistent protection against candidiasis-related death in allogeneic marrow transplant recipients: long term follow-up of a randomized, placebo-controlled trial

    Blood

    (2000)
  • G.P. Bodey et al.

    The epidemiology of Candida glabrata and Candida albicans fungemia in immunocompromised patients with cancer

    Am J Med

    (2002)
  • D. Hadjiliadis

    Special considerations for patients undergoing lung transplantation for cystic fibrosis

    Chest

    (2007)
  • E.M. Hodson et al.

    Antiviral medications to prevent cytomegalovirus disease and early death in recipients of solid organ transplants: a systematic review of randomised controlled trials

    Lancet

    (2005)
  • A.J. Wolff et al.

    Pulmonary manifestations of HIV infection in the era of highly active antiretroviral therapy

    Chest

    (2001)
  • M.J. Rosen et al.

    Critical care of immunocompromised patients: human immunodeficiency virus

    Crit Care Med

    (2006)
  • G.R. Bernard et al.

    Efficacy and safety of recombinant human activated protein C for severe sepsis

    N Engl J Med

    (2001)
  • D. Annane et al.

    Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock

    JAMA

    (2002)
  • E. Rivers et al.

    Early goal directed therapy in the treatment of severe sepsis and septic shock

    N Engl J Med

    (2001)
  • The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome

    N Engl J Med

    (2000)
  • G. Hilbert et al.

    Non-invasive ventilation in immunosuppressed patients with pulmonary infiltrates, fever and acute respiratory failure

    N Engl J Med

    (2001)
  • F.G. Duran et al.

    Pulmonary complications following orthotopic liver transplant

    Transpl Int

    (1998)
  • R.M. Kotloff et al.

    Pulmonary complications of solid organ and hematopoietic stem cell transplantation

    Am J Respir Crit Care Med

    (2004)
  • C.P. Heussel et al.

    Early detection of pneumonia in febrile neutropenic patients: use of thin-section CT

    AJR Am J Roentgenol

    (1997)
  • J.T. Barloon et al.

    High-resolution ultrafast chest CT in the management of febrile bone marrow transplant patients with normal or nonspecific chest roentgenograms

    Chest

    (1991)
  • D.L. Paterson et al.

    Invasive aspergillosis in transplant recipients

    Medicine

    (1999)
  • T.F. Paterson et al.

    Invasive aspergillosis: disease spectrum, treatment practices, and outcomes

    Medicine

    (2000)
  • A. Rano et al.

    Pulmonary infiltrates in non-HIV immunocompromised patients; a diagnostic approach using non invasive and bronchoscopic procedures

    Thorax

    (2001)
  • D.A. White et al.

    The utility of open lung biopsy in patients with hematologic malignancies

    Am J Respir Crit Care Med

    (2002)
  • B.R. Foerster et al.

    Intracranial infections: clinical and imaging characteristics

    Acta Radiol

    (2007)
  • E. Mylonakis et al.

    Central nervous system infection with Listeria monocytogenes; 33 years of experience from a general hospital and review of 776 cases from the literature

    Medicine

    (1998)
  • M. Paul et al.

    Beta lactam monotherapy versus beta lactam-aminoglycoside combination therapy for fever with neutropenia: systematic review and meta-analysis

    BMJ

    (2003)
  • M. Paul et al.

    Empirical antibiotic monotherapy for febrile neutropenia: systematic review and meta-analysis of randomized controlled trials

    J Antimicrob Chemother

    (2006)
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