HIV and ID Observations

I am currently attending on the inpatient service, which means I spend a good chunk of my day seeing new ID consults and rounding on follow-ups.  As I’m sure is true in most hospitals, many of these consults are from the intensive care units (ICUs). 

After 18 years in this ID business, I confess I still find myself quite challenged by ICU Infectious Diseases.  It’s not due to the complexity of the cases, in fact just the opposite — paradoxically, there’s a sameness to the cases that is worlds away from the wonderful variety of ID/HIV elsewhere:  the outpatient with fever of unknown origin, or the inpatients with endocarditis, meningitis, orthopedic infection, HIV-related complication, or tropical fever (the stuff that makes up much of the rest of the consult volume).  One intensivist says that once patients get past the first few days after admission, most of the medical issues they face are similar. 

From the ID perspective, this means “rounding up the usual suspects,” including searching for line infections, UTIs, C diff, sinusitis, pancreatitis, surgical site infections, acalculous cholecycstitis, drug fever, infected pressure ulcers and — especially — nosocomial pneumonia. 

There’s a sameness to these investigations that makes individualizing care difficult, and often forces us to focus on the (abundant) microbiologic data as distinguishing characterisitics.  Just how resistant are the bacteria isolated from this patient’s respiratory sample?  How many different possible pathogens can be cultured from a surgical drain?  What is the significance of candida isolated from several non-sterile sites?  How about those few colonies of coagulase negative staph on a removed line tip?

So where to go for help?  For a comprehensive “how to” for this patient population, check out the recent IDSA/American College of Critical Care Guidelines.  It’s an impressive document.

And give yourself plenty of time — it’s 20 pages long, and has over 200 references. 

(In Part II, the issue of empiric antibiotics in the ICU.)