Fever in short gut patients with a central venous line (<18 years)
Inclusion Criteria
- GI patient with indwelling central venous catheter (i.e. - Broviac, Hickman, port, PICC)
- Fever (≥ 38.0 C (100.4 F) in the past 24 hours)
Exclusion Criteria
- Positive blood culture that has not been fully treated
TPN dependent, but stopped or unavailable?
Cephalosporin allergy?
Grown high risk isolate in past 3 months?
Meet SIRS criteria?
NS Bolus
Severe sepsis?
Ceftriaxone injection
Cefepime injection
Adequate response?
Admit to Floor
Vancomycin injection
- Aggressive resuscitation
- Obtain further IV access
- Fluid resuscitation as needed
- Vasopressors as needed
Admit to ICU
Fever in this population is an emergency
- Pateints with intestinal failure, including short gut syndrome, are at increased risk for bacteremia and sepsis. There is increased risk of infection with gram positive skin flora due to indwelling lines and infection with gram negative rods due to translocation from abnormal gut anatomy & small bowel bacterial overgrowth.
Population specific information
- Blood cultures should always be drawn directly from the central line.
- Consider additional intravenous access if aggressive fluid resuscitation is indicated, however, ANTIBIOTICS SHOULD ALWAYS BE GIVEN THROUGH THE CENTRAL VENOUS CATHETER.
- Some short gut patients take no significant PO. Because of this, they are at high risk for hypoglycemia and dehydration should their TPN be stopped. Continue to run either their TPN or D10 containing fluids during their typical TPN run-time.
- Keep in mind that many oral medications will not be adequately absorbed in short gut patients and intravenous administration is preferred.
Meropenem infusion
Goal: Administer empiric antibiotics via central venous catheter within 1 hour of presentation.
Viral URI AND Tmax < 38.5 C?
Inspect all CVCs for integrity as line breaks/cracks are risk factors for infection, then obtain labs.
Complete Blood Count, Serum
Complete Metabolic Panel, Serum
Blood Culture (Aerobic and Anaerobic), Serum
C-Reactive Protein (CRP), Serum
ISTAT Venous Blood Gas and Lactate, Serum
Magnesium, Serum
Phosphorus, Serum
Prothrombin time (PT)
Partial Thromboplastin Time (PTT)
Procalcitonin, Serum
- Admit to floor
- Respiratory PCR swab
- Contact/Droplet Isolation
- Defer initiation of antibiotics and monitor vital signs and I/O closely
- Note regarding observation without antibiotics:
- To be observed without antibiotics, the patient must continue to meet ALL of the following criteria:
- Remains non-toxic appearing
- Temperature no higher than 38.5°C (101.3°F)
- No leukocytosis
- Normal procalcitonin (<0.3)
- Potential fever source identified
- Should any of the above criteria NOT be met, pursue usual management with empiric antibiotic therapy.
SIRS criteria (≥ 2 criteria, one of which must be abnormal temperature or WBC)
- Abnormal core temperature >38.5°C (101.3°F) or <36°C (96.8°F)
- Rectal, bladder, oral, or central probe
- Tachycardia for age, or if < 1 year, bradycardia
- Tachypnea for age or mechanical ventilation for an acute pulmonary process
- WBC elevated or depressed for age, or >10 percent bands
High-risk blood-stream isolates
- Enterobacter cloacae (specifically cloacae NOT aerogenes)
- Citrobacter species
- Acinetobacter species
- Pseudomonas species
D10 NS infusion
Glucose by Meter, POC
Inpatient management includes:
- Close monitoring for signs if SIRS/ Sepsis, including clinical appearance, vital signs, urine output
- Ongoing fluid resuscitation
- Empiric antibiotic therapy administered through the central venous catheter until culture isolate is identified or culture is negative x48h
- Daily blood cultures via central venous catheter
- If any isolate grows on culture, initiate daily ethanol lock therapy x5days (if appropriate for line type)
- Given the high frequency of antibiotic use in this population, aim toward as narrow, targeted coverage as much as possible to avoid fostering antibiotic resistance.
- If an isolate grows on culture, antibiotic coverage should be narrowed promptly upon receipt of isolate sensitivities.
- If a Gram+ isolate grows on culture, narrow antibiotic coverage once mecA testing result is available (before full sensitivities). For Staph aureus - convert Vancomycin to Cefazolin immediately if not MRSA.
- If the patient has an unclear allergy to a cephalosporin, consider allergy & immunology consultation for allergy testing and possible densensitization.
