Complications
Although pleural effusions are common, empyemas occur in just 5% to 10% among those with an effusion.[91] Infections may spread directly or haematogenously from intra-parenchymal tissue to the pleural space.
All effusions should be suspected to be empyemas, especially if they are unilateral, are not cleared with diuresis, and are not in the context of heart failure.
A CT scan will differentiate an effusion from pulmonary oedema, but a diagnostic thoracentesis is required to rule out an empyema or abscess. Guidelines for the management of parapneumonic effusions are available.[92]
Sepsis can occur haematogenously from a pathogen causing HAP. Two sets of blood cultures should be checked at least 30 minutes apart to detect the presence of persistent bacteraemia, which would support a diagnosis of endocarditis.
A differential should be obtained manually with an FBC to determine the degree of band formation.
Follow your local protocol for investigation and treatment of all patients with suspected sepsis, or those at risk. In the UK, arrange urgent review by a senior clinical decision-maker (e.g., ST4 level doctor) if you suspect sepsis.[32] This should be arranged: within 30 minutes for a patient who is critically ill (e.g., NEWS2 score of 7 or more, evidence of septic shock, or other significant clinical concerns); within 1 hour for a patient who is severely ill (e.g., NEWS2 score of 5 or 6). Start treatment promptly. Determine urgency of treatment according to likelihood of infection and severity of illness, or according to your local protocol.[32][41]
Pulmonary embolism is difficult to diagnose because it is manifested by vague symptoms (primarily, shortness of air and tachycardia). In addition, taking a critically ill patient to radiology for a spiral CT scan may be complicated and dangerous.
Clostridium difficile colitis typically occurs after broad-spectrum antibiotic use. It is prudent to order stool testing. Testing may need to be repeated if toxin or antigen tests are used, as the sensitivity is only 80% (depending on the commercial kit used). If suspicion is high, treatment should be given.
High leukocytosis may occur as well, so an FBC should be ordered. If toxic megacolon is suspected, a CT scan of the abdomen should be performed and a surgeon called. C difficile infection may be prevented by limiting antimicrobial use.
Obtaining another toxin test from the stool for cure is not appropriate, as patients shed toxin for weeks after having colitis; thus, cure is a clinical decision.
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