Complications
Although pleural effusions are common, empyemas occur in just 5% to 10% of those with an effusion.[141] Infections may spread directly or hematogenously from intraparenchymal 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 edema, but a diagnostic thoracentesis is required to rule out an empyema or abscess. Guidelines for the management of parapneumonic effusions are available.[142]
Sepsis can occur hematogenously from a pathogen causing HAP. Two sets of blood cultures should be checked at least 30 minutes apart to detect the presence of persistent bacteremia, which would support a diagnosis of endocarditis.
A differential should be obtained manually with a CBC to determine the degree of band formation.
Guidelines for the management of sepsis should be followed.[143]
Pulmonary embolism is difficult to diagnose because it is manifested by vague symptoms (primarily, shortness of breath and tachycardia). In addition, taking a critically ill patient to radiology for a spiral computed tomography (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 a complete blood count (CBC) 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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