key: cord-020560-jnemlabp
authors: Tewari, Hemant; Nangia, Vivek
title: Severe Tropical Infections
date: 2012-03-09
journal: ICU Protocols
DOI: 10.1007/978-81-322-0535-7_51
sha: 
doc_id: 20560
cord_uid: jnemlabp

Severe infection with multiorgan involvement is one of the most common cause of ICU admission in tropical countries. Close monitoring and supportive therapy is the mainstay of treatment in most of these infections, but some of them have specific therapies. Rapid identification of treatable infection is imperative for a better outcome.

Severe infection with multiorgan involvement is one of the most common cause of ICU admission in tropical countries. Close monitoring and supportive therapy is the mainstay of treatment in most of these infections, but some of them have speci fi c therapies. Rapid identi fi cation of treatable infection is imperative for a better outcome.

Fluid resuscitation is the mainstay of initial management in most of the tropical • infections as they present late, have predominant diarrheal component, and are usually dehydrated. Close monitoring for volume overload and pulmonary edema should be done. • Recent trial conducted in Africa on a pediatric population with severe sepsis • have shown fl uid loading may be detrimental in this population. Patients presenting with encephalopathic syndromes need airway assessment • and assisted ventilation. While resuscitation is going on, send investigations: • Complete blood count-neutropenia is a common feature in many tropical infections. Leptospirosis typically has leukocytosis. Imaging: chest x-ray, echo, ultrasound of abdomen, and CT scan (when • indicated).

Step 5: Start general supportive care and speci fi c organ support (see Chap. 79 ) Many tropical infections are self-limiting. Close monitoring and general organ • support in the initial days or weeks of viremia or parasitemia will salvage many patients.

Step 6: Initiate empirical therapy based on initial presentation Speci fi c therapy is available only for a few tropical infections. •

Depending on the clinical presentation and endemicity of a particular infection • in the geographical region, an educated guess for initial therapy has to be decided till de fi nitive investigations are available. Usually, intravenous ceftriaxone, 2 g IV twice daily, to cover typhoid fever and • leptospirosis is started if MP and dual antigen is negative.

In patients with shock and MODS, broad-spectrum antibiotics should be started • immediately. De-escalate antibiotics once speci fi c infection is identi fi ed.

Step 7: Start speci fi c treatment once the diagnosis is con fi rmed Dengue • A protocol for intravenous fl uid therapy has been developed by the World -Health Organization (WHO). An initial bolus of 5% dextrose in normal saline or Ringer lactate (20 mL/kg of body weight) is infused over 15 min, followed by continuous infusion (10-20 mL/kg/h, depending on the clinical response) until vital signs and urine output normalize. Crystalloids are equally effective as colloids in fl uid resuscitation. -Normalization of the hematocrit is an important goal of early fl uid repletion. -However, a normal or low hematocrit may be misleading in patients with overt bleeding and severe hypovolemia. Close clinical observation is essential, even after normal blood volume is restored, because patients can develop shock for 1-2 days after initial fl uid resuscitation, which represents the period of increased vascular permeability in dengue hemorrhagic fever. Plasmodium falciparum infections acquired in areas without chloroquineresistant strains, patients should be treated with oral chloroquine. A chloroquine dose of 600 mg base (=1,000 mg salt) should be given initially, followed by 300 mg base (=500 mg salt) at 6, 24, and 48 h after the initial dose for a total chloroquine dose of 1,500 mg base (=2,500 mg salt). For chloroquine-resistant strains, treatment options are as follows: -Quinine sulfate: Quinine has a rapid onset of action and, in combination • with tetracycline, doxycycline, or clindamycin, it has been shown to be a very ef fi cacious treatment option for P. falciparum infections acquired in regions with chloroquine-resistant strains. Artemisinin derivatives clear parasites very rapidly, are now a key compo-• nent of malaria treatment worldwide, and have been shown to reduce mortality in severe malaria compared with parenteral quinine. Artemisinin-based combination therapies, including artesunate-me fl oquine, artemether-lumefantrine, artesunate-amodiaquine, and dihydroartemisinin-piperaquine, are highly ef fi cacious. Under the CDC protocol, intravenous artesunate is administered in four • equal doses of 2.4 mg/kg of body weight over a period of 3 days. The dosing schedule recommended by the WHO entails doses every 12 h on day 1 and then once daily. Up to 7 days of therapy may occasionally be indicated in very ill patients. •

Fluid boluses signi fi cantly increased 48-h mortality in critically ill children with impaired perfusion in the resource-limited settings in Africa

Intravenous artesunate for the treatment of severe malaria

Three major studies regarding the use of intravenous artesunate are reviewed. Several international studies comparing intravenous quinine and artesunate conclude that artesunate has the highest treatment success

Dengue haemorrhagic fever: diagnosis, treatment, prevention and control

World Health Organization. Guidelines for prevention and control of leptospirosis. Geneva: World Health Organization

World Health organization. Guidelines for malaria Geneva: World Health Organization

Epidemic of leptospirosis: an ICU experience

Leptospirosis is an important infection with high mortality when associated with organ dysfunction. The poor prognostic factors are preponderance of male sex, alcohol dependence, age group more than 50 years, MODS, acute respiratory distress syndrome (ARDS), presence of acidosis, and need for mechanical ventilation

The Hospital for Tropical Diseases is dedicated to the prevention, diagnosis, and treatment of tropical diseases and travel-related infections.

An extensive repository on guidelines for many tropical infections