{"id":25493,"date":"2018-02-27T00:00:00","date_gmt":"2018-02-26T21:00:00","guid":{"rendered":"https:\/\/tatd.org.tr\/blog\/2018\/02\/27\/son-literatur-isiginda-acil-serviste-atese-yaklasim-eski-koye-yeni-adet-mi\/"},"modified":"2021-11-20T03:04:40","modified_gmt":"2021-11-20T00:04:40","slug":"son-literatur-isiginda-acil-serviste-atese-yaklasim-eski-koye-yeni-adet-mi","status":"publish","type":"post","link":"https:\/\/tatd.org.tr\/en\/haber-ve-duyuru\/son-literatur-isiginda-acil-serviste-atese-yaklasim-eski-koye-yeni-adet-mi\/","title":{"rendered":"Son literat\u00fcr \u0131\u015f\u0131\u011f\u0131nda acil serviste ate\u015fe yakla\u015f\u0131m: Eski k\u00f6ye yeni adet mi?"},"content":{"rendered":"

Prof. Dr. \u00d6zg\u00fcr Karc\u0131o\u011flu <\/a><\/strong><\/p>\n

\u0130stanbul EAH, Fatih.<\/strong><\/p>\n

Ate\u015f (pireksi) enfeksiyonun en s\u0131k bulgusudur. Enfeksiy\u00f6z veya non-enfeksiy\u00f6z nedenlerle ve v\u00fccudun ate\u015fi tetikleyen maddeye (pirojene) yan\u0131t\u0131 olarak ortaya \u00e7\u0131kar. Hipotalamustan kontrol edilir. Bir\u00e7ok etiyolojik nedenle g\u00f6r\u00fclebilen kompleks bir s\u00fcre\u00e7tir. Her enfeksiyon olgusunda ate\u015f olmaz, her ate\u015fli olgu da enfeksiyona sahip de\u011fildir.<\/p>\n

Bir semptom olarak ate\u015fin nas\u0131l y\u00f6netilmesi\/tedavi edilmesi gerekti\u011fine ili\u015fkin net bir bilgi yoktur. 2000\u2019den sonra yeti\u015fkin hastalarda ate\u015f tedavisinde ila\u00e7 kullan\u0131m\u0131 ile ilgili sadece 5 ara\u015ft\u0131rma yay\u0131nlanm\u0131\u015f olmas\u0131 durumu olduk\u00e7a ilgin\u00e7 k\u0131lmaktad\u0131r (1-5).<\/p>\n

Eksojen veya endojen pirojenlere tepki olarak ate\u015f yan\u0131t\u0131 olu\u015fur. Gram-pozitif bakteriler, streptokoklara ait superantijenler eksojen pirojenlere \u00f6rnektir. \u0130nflamatuar kaskadda sitokinler, bunlar\u0131n tetikledi\u011fi prostaglandinler rol oynar, bunlar da hipotalamusta cAMP \u00fczerinden termostat noktas\u0131n\u0131 yukar\u0131ya \u00e7ekerek ate\u015fe neden olurlar. Benzer s\u00fcre\u00e7 malignite ve ba\u015fka baz\u0131 hastal\u0131klarda da i\u015fler.<\/p>\n

Yo\u011fun bak\u0131m hastalar\u0131nda ate\u015fin parasetamol ile tedavi edildi\u011finde prognozun iyile\u015fmedi\u011fine YB\u2019da kal\u0131\u015f s\u00fcresinin k\u0131salmad\u0131\u011f\u0131na dair bilgiler s\u00f6z konusudur (6).<\/p>\n

Yeti\u015fkin acil servis ba\u015fvurular\u0131n\u0131n %5\u2019i ve ya\u015fl\u0131lar\u0131n ba\u015fvurular\u0131n\u0131n %15\u2019i ate\u015f ile ili\u015fkilidir. Pulmoner emboli, ICH\/SVO, malignite, otoimmun nedenler, n\u00f6bet, kan transf\u00fczyonu, tiroid sorunlar\u0131, Munchausen sendromu ve kullan\u0131lan ila\u00e7lar da ate\u015fe neden olabilir. Tablo 1\u2019de ate\u015fe neden olan enfeksiy\u00f6z ve non-enfeksiy\u00f6z hastal\u0131klar listelenmi\u015ftir.<\/p>\n

Muayene bulgular\u0131: <\/strong><\/p>\n

Her hastada oldu\u011fu gibi fizik bak\u0131 ya\u015famsaldan ba\u015flayarak tepeden-t\u0131rna\u011fa y\u00f6ntemiyle ilerler.<\/p>\n

Ate\u015f: <\/strong>Aksiller ve oral ate\u015f \u00f6l\u00e7\u00fcm\u00fc \u00f6zellikle ya\u015fl\u0131larda yanl\u0131\u015f sonu\u00e7 verebilmektedir. \u00a0Oral ate\u015f \u00f6l\u00e7\u00fcm\u00fc yayg\u0131n olmakla birlikte g\u00fcvenilir de\u011fildir. 75 \u00e7al\u0131\u015fman\u0131n al\u0131nd\u0131\u011f\u0131 bir meta-analizde oral ate\u015f \u00f6l\u00e7\u00fcm\u00fcn\u00fcn merkezi ate\u015f \u00f6l\u00e7\u00fcm\u00fcne g\u00f6re duyarl\u0131l\u0131\u011f\u0131 ancak %64 civar\u0131nda bulunmu\u015ftur, \u00f6zg\u00fcll\u00fc\u011f\u00fc ise %96\u2019d\u0131r \u00a0(7). Bu nedenle, oral termometre hastay\u0131 hipotermik veya ate\u015fli buldu ise tekrarlamaya gerek yoktur. Ancak hasta normotermik \u00e7\u0131km\u0131\u015f fakat klinik \u015f\u00fcphe y\u00fcksek ise merkezi s\u0131cakl\u0131k \u00f6l\u00e7\u00fclmesi daha yararl\u0131 olacakt\u0131r (8).<\/p>\n

Tan\u0131sal testler:<\/strong>Tam kan say\u0131m\u0131, rutin idrar bak\u0131s\u0131, akci\u011fer grafisi hastadaki klinik bulgular ve \u00f6yk\u00fcye dayanarak istenmesi gereken testlerdir.<\/p>\n

CRP, ESR ve prokalsitonin (PCT) \u00fczerine \u00e7ok say\u0131da ara\u015ft\u0131rma yap\u0131lm\u0131\u015f olsa da istenen duyarl\u0131l\u0131k ve \u00f6zg\u00fcll\u00fc\u011fe ula\u015f\u0131lamam\u0131\u015ft\u0131r.<\/p>\n

PCT viralden \u00e7ok bakteriyel enfeksiyonda y\u00fckselen bir peptiddir. Antibiyotik tedavisi PCT rehberli\u011finde yap\u0131ld\u0131\u011f\u0131nda daha az antibiyotik kullan\u0131ld\u0131\u011f\u0131 belirlenmi\u015ftir (9). Ancak mortalite \u00fczerinde yarar\u0131 g\u00f6sterilmemi\u015ftir.<\/p>\n

Serum CRP d\u00fczeyi\u00a0 4-6 saat i\u00e7inde y\u00fckselmeye ba\u015flay\u0131p her 8 saatte 2\u2019ye katlan\u0131r. 35-60 saat i\u00e7inde zirve d\u00fczeye ula\u015f\u0131r (10, 11). Sonu\u00e7ta 12 saatten fazla s\u00fcren ate\u015fi olan bir olguda CRP y\u00fcksekli\u011fi hemen daima bakteriyel enfeksiyonu g\u00f6sterir (12). \u00d6rne\u011fin sepsis i\u00e7in 50 mg\/L \u00fczerindeki CRP d\u00fczeyleri %72-98 sensitif, %66-75 spesifik bulunmu\u015ftur (13).<\/p>\n

Kan k\u00fclt\u00fcr\u00fc:<\/strong><\/p>\n

Bakteriyemi saptanmas\u0131nda en duyarl\u0131 y\u00f6ntem olarak g\u00f6r\u00fclen kan k\u00fclt\u00fcr\u00fc, ate\u015f, \u00fc\u015f\u00fcme-titreme, l\u00f6kositoz, fokal enfeksiyon, veya sepsis d\u00fc\u015f\u00fcn\u00fclen olgularda s\u0131kl\u0131kla al\u0131nmaktad\u0131r.\u00a0 Septik \u015fok \u015f\u00fcphesi olan olguda veya klinik y\u00f6netimi de\u011fi\u015ftirece\u011fi d\u00fc\u015f\u00fcn\u00fcl\u00fcyorsa kan k\u00fclt\u00fcrleri al\u0131nmal\u0131d\u0131r. Rutin olarak her ate\u015fli olguda kan k\u00fclt\u00fcr\u00fc al\u0131nmamal\u0131d\u0131r. Yanl\u0131\u015f-pozitif kan k\u00fclt\u00fcr\u00fc hastanede kal\u0131\u015f s\u00fcresini uzat\u0131p, gereksiz antibiyotik kullan\u0131m\u0131n\u0131 art\u0131rarak zarar vermektedir.<\/p>\n

\u0130mmun supresyondaki olgularda ciddi enfeksiyon kayna\u011f\u0131 bulunma olas\u0131l\u0131\u011f\u0131 y\u00fcksektir.\u00a0 Toplum k\u00f6kenli pn\u00f6moni (TKP), sell\u00fclit (fasiyal hari\u00e7), hemodinamik durumu stabil olgularda yararl\u0131l\u0131\u011f\u0131 net de\u011fildir.TKP\u2019li olgularda yanl\u0131\u015f-pozitif kan k\u00fclt\u00fcr\u00fc oran\u0131 %8 civar\u0131ndad\u0131r (14).<\/p>\n

Sepsis, menenjit, komplike piyelonefrit, endokarditte ve hastane k\u00f6kenli pn\u00f6monide kan k\u00fclt\u00fcrleri gereklidir (15). Ancak sell\u00fclit, basit piyelonefrit ve TKP olgular\u0131nda gerekli de\u011fildir (Tablo 2). Bu karar\u0131n verilmesinde klinik durumun \u00f6nemli oldu\u011fu bir\u00e7ok belgede dile getirilmi\u015ftir. ABD\u2019de bir 2017 \u00e7al\u0131\u015fmas\u0131nda TKP nedeniyle yat\u0131r\u0131lan \u00f6nceden sa\u011fl\u0131kl\u0131 2705 \u00e7ocuk hastan\u0131n %31\u2019inde kan k\u00fclt\u00fcr\u00fc al\u0131nm\u0131\u015f, sadece 12\u2019sinde (%0.4) pozitiflik saptanm\u0131\u015ft\u0131r (16). Bu olgular\u0131n da hi\u00e7birinde kan k\u00fclt\u00fcr sonucunun tedavi veya klinik gidi\u015fi de\u011fi\u015ftirecek bir etkisi bulunmam\u0131\u015ft\u0131r. Yeni yay\u0131nlarda komorbiditesi olmayan TKP\u2019li olgularda kan k\u00fclt\u00fcr\u00fc al\u0131nmamas\u0131 daha net olarak vurgulanmaktad\u0131r (17).<\/p>\n

Pn\u00f6monili hastalarda ger\u00e7ek bakteriyemi bulunmas\u0131 i\u00e7in hastalarda kronik karaci\u011fer hastal\u0131\u011f\u0131, \u201ckonf\u00fczyon, \u00fcre y\u00fcksekli\u011fi, solunum say\u0131s\u0131 ve kan bas\u0131nc\u0131 ve ya\u015f\u201dtan olu\u015fan\u00a0 CURB-65 skoru 4 veya 5 olmas\u0131,\u00a0Pneumonia Severity Index (PSI) class V olmas\u0131 ba\u011f\u0131ms\u0131z olarak risk fakt\u00f6r\u00fcd\u00fcr.<\/p>\n

Kan k\u00fclt\u00fcr\u00fc i\u00e7in iki farkl\u0131 v\u00fccut b\u00f6lgesinden en az 7\u2019\u015fer mL kan al\u0131nmal\u0131d\u0131r.<\/p>\n

Ate\u015f tedavi edilmeli mi? <\/strong><\/p>\n

Ate\u015fin antibiyotiklerin etkisini art\u0131rd\u0131\u011f\u0131, mikroorganizmalar\u0131n \u00e7o\u011falmas\u0131n\u0131 engelledi\u011fi d\u00fc\u015f\u00fcn\u00fclmektedir. Yine baz\u0131 \u00e7al\u0131\u015fmalarda erken d\u00f6nemde y\u00fcksek ate\u015fin \u00f6l\u00fcm riskini d\u00fc\u015f\u00fcrd\u00fc\u011f\u00fc bildirilmi\u015ftir (18,19).<\/p>\n

1 gr parasetamol inf\u00fczyonu ile ate\u015fin etkin olarak d\u00fc\u015f\u00fcr\u00fclebildi\u011fine dair bilgilerimiz olduk\u00e7a yeni tarihlidir. Plasebo ile tedavi edilenlerin %38.5\u2019i, parasetamol ile tedavi edilenlerin %80\u2019i ilk 6 saatte ate\u015fi d\u00fc\u015f\u00fcr\u00fclebiliyor (5). Parasetamol ortalama 3 saat civar\u0131nda ate\u015fi normalize etmektedir. Kan-beyin bariyerini ge\u00e7erek a\u011fr\u0131 kesici etkinlikle ate\u015f d\u00fc\u015f\u00fcr\u00fcc\u00fc etkinli\u011fi birle\u015ftirmektedir. Parasetamol uygulamas\u0131nda karaci\u011fer yetmezli\u011fi ve allerji geli\u015fimi d\u0131\u015f\u0131nda dikkatli olunmas\u0131 gereken bir durum yoktur.<\/p>\n

Antibiyotik gereklili\u011fine nas\u0131l karar verelim? <\/strong><\/p>\n

Basit enfeksiyonlarda gereksiz antibiyotik yaz\u0131m\u0131 sadece hekimlerin de\u011fil halk\u0131n da tart\u0131\u015ft\u0131\u011f\u0131 ve d\u00fcnya \u00f6l\u00e7e\u011finde bir sorundur. Maliyet, antibakteriyel diren\u00e7 geli\u015fimi, yan etkiler gibi bir\u00e7ok alt ba\u015fl\u0131\u011f\u0131 vard\u0131r.<\/p>\n

Acil serviste ate\u015fli olgular\u0131n y\u00f6netiminde antibiyotik uygulama karar\u0131 \u00e7o\u011funlukla ampirik olarak verilmektedir. Birka\u00e7 ay \u00f6nce yay\u0131nlanan bir Cochrane review\u2019da solunum yolu enfeksiyonlar\u0131nda hastaya re\u00e7etenin verilmesi fakat ilaca ba\u015flaman\u0131n geciktirilmesi (Delayed antibiotic prescriptions) iyi bir y\u00f6ntem olarak g\u00f6r\u00fclmektedir (20). Hasta memnuniyetinin bu yolla artt\u0131\u011f\u0131 da bilinmektedir (20).<\/p>\n

Hemen antibiyotik ba\u015flama k i\u00e7in nas\u0131l do\u011fru karar verebiliriz? Asl\u0131nda ayr\u0131nt\u0131l\u0131 \u00f6yk\u00fc ve fizik bak\u0131 ile b\u00fcy\u00fck oranda bu karar olu\u015facakt\u0131r. Test-\u00f6ncesi olas\u0131l\u0131k (T\u00d6O) olu\u015fturulmas\u0131 \u00f6nemlidir. Kemoterapi alma \u00f6yk\u00fcs\u00fc, kortikosteroid kullan\u0131m\u0131, al\u0131nan ila\u00e7lar, diyabet, akci\u011fer hastal\u0131klar\u0131 gibi komorbid durumlar\u0131n hepsi yol g\u00f6stericidir. Bir\u00e7ok hekim tam kan say\u0131m\u0131, rutin idrar bak\u0131s\u0131, akci\u011fer grafisi gibi testleri her ate\u015fli olguda rutin olarak istese de hastaya \u00f6zel istenen testlerin yararl\u0131l\u0131\u011f\u0131 daha y\u00fcksektir. Se\u00e7ilmi\u015f olgularda viral antijen testleri, idrar\/kan k\u00fclt\u00fcrleri de yararl\u0131 olabilir.<\/p>\n

Antibiyotiklerin hemen ba\u015flanmas\u0131n\u0131n ya\u015fam kurtar\u0131c\u0131 olabildi\u011fi durumlar aras\u0131nda septik \u015fok, akut bakteriyel menenjit, immun suprese hastalardaki baz\u0131 enfeksiyonlar, endokarditi febril n\u00f6tropeni gibi enfeksiyonlar bulunmaktad\u0131r. \u00d6rne\u011fin menenjitte lomber ponksiyon sonucu veya tomografi beklenmeden antibiyotik ba\u015flanmal\u0131d\u0131r (21).<\/p>\n

Acil ko\u015fullarda s\u0131k kar\u015f\u0131la\u015f\u0131lan durumlardan biri, kayna\u011f\u0131 belirsiz sepsistir. Bu olgularda gerekli k\u00fclt\u00fcrler al\u0131n\u0131p Piperasilin\/tazobaktam4.5 gr IV\u00b1Vancomycin (MRSA riski varsa) \u00b1 Gentamicin ba\u015flanmas\u0131 uygundur. MRSA riski santral kateter veya di\u011fer enstrumantasyon yerle\u015ftirilmesi, 3 ay i\u00e7inde 2 hafta veya daha fazla hastanede yat\u0131\u015f, bak\u0131m evi vb.de kalma, enjeksiyon ile ila\u00e7 kullan\u0131m\u0131 durumlar\u0131nda d\u00fc\u015f\u00fcn\u00fcl\u00fcr.<\/p>\n

Antibiyotik-d\u0131\u015f\u0131 tedaviler: <\/strong><\/p>\n

Anaerobik enfeksiyonlarda (koku ve yara g\u00f6r\u00fcn\u00fcm\u00fc ile \u015f\u00fcphelenilir) \u00f6l\u00fc dokunun uzakla\u015ft\u0131r\u0131lmas\u0131, cerrahi debridman ya\u015famsal \u00f6nem ta\u015f\u0131r.<\/p>\n

Sepsis ve septik \u015fok olgular\u0131nda kortikosteroid tedavisi giderek daha fazla savunulmaktad\u0131r. Yak\u0131n tarihli bir \u00e7al\u0131\u015fmada erken d\u00f6nemde kortikosteroid alan septik \u015foklu \u00e7ocuklar\u0131n iyile\u015fme s\u00fcresinin k\u0131sald\u0131\u011f\u0131 bildirilmi\u015ftir (22).<\/p>\n

Sepsiste ate\u015f: <\/strong><\/p>\n

Bakteriyel menenjit ve sepsisli olgularda ate\u015fin olmamas\u0131 durumunda mortalite artmaktad\u0131r. Ate\u015fin organizmay\u0131 koruyucu rol\u00fc bu bulgudan da anla\u015f\u0131lmaktad\u0131r (23,24). SIRS kriterleri hem hipertermi hem de hipotermiyi sepsis g\u00f6stergesi kabul etmi\u015ftir. Ancak her ikisinin de saptanamad\u0131\u011f\u0131 septik hastalar da g\u00f6r\u00fclebilmektedir. Geriatrik sepsisli olgular\u0131n yakla\u015f\u0131k d\u00f6rtte birinin ate\u015f ve di\u011fer yan\u0131tlar\u0131n\u0131n k\u00fcntle\u015fti\u011fi bildirilmi\u015ftir (25).<\/p>\n

Acil servise ilk ba\u015fvuruda ate\u015fin olmamas\u0131 ve ilk bikarbonat d\u00fczeyinin acilden hospitalizasyon sonras\u0131 48 saat i\u00e7inde k\u00f6t\u00fcle\u015fmeyi ba\u011f\u0131ms\u0131z \u015fekilde \u00f6ng\u00f6ren de\u011fi\u015fkenler oldu\u011fu bildirilmi\u015ftir. qSOFA skorlamas\u0131nda ise ate\u015f \u00f6nemsenmemi\u015ftir. Bu \u00f6l\u00e7ek acil serviste kullan\u0131m i\u00e7in \u00f6nerilmi\u015f olsa da, bunun sadece mortalite ve k\u00f6t\u00fcle\u015fmeyi \u00f6ng\u00f6rd\u00fc\u011f\u00fc, sepsis tan\u0131s\u0131 koymad\u0131\u011f\u0131 bilinmelidir.<\/p>\n

Non-enfeksiy\u00f6z durumlarda ate\u015f:<\/strong><\/p>\n

Hipertermi ile ate\u015f farkl\u0131d\u0131r. Hipertermide pirojenlere yan\u0131t geli\u015fmedi\u011finden antipiretiklere yan\u0131t da yoktur.<\/p>\n

Pulmoner embolili ve ate\u015fi olan olgular\u0131n %14 ila 18\u2019inde bunun d\u0131\u015f\u0131nda ate\u015f nedeni bulunmam\u0131\u015ft\u0131r (26). Ate\u015fli bir olguda PE ile sepsisin ayr\u0131lmas\u0131nda zorluk varsa s\u0131kl\u0131kla akci\u011fer grafisi tan\u0131sal olmayaca\u011f\u0131ndan akci\u011fer tomografisi ve angio-BT gibi ileri incelemelere gidilmelidir.<\/p>\n

Sonu\u00e7:<\/strong> Acil servis ve birincil bak\u0131 kurumlar\u0131nda en s\u0131k ba\u015fvuru yak\u0131nmalar\u0131ndan biri olan ate\u015fe nas\u0131l yakla\u015f\u0131laca\u011f\u0131na ili\u015fkin bir netlik yoktur. Hastan\u0131n klinik bulgular\u0131, komorbidite durumu, vital bulgular\u0131 ve risk fakt\u00f6rleri \u0131\u015f\u0131\u011f\u0131nda incelemeler ve antibiyotik gibi tedavilere karar verilir. Bu karar\u0131n son derece ki\u015fiye \u00f6zel geli\u015ftirilece\u011fi a\u00e7\u0131kt\u0131r. \u00d6rne\u011fin ate\u015fin v\u00fccudun koruyucu mekanizmalar\u0131 i\u00e7inde oldu\u011fu, u\u00e7 de\u011ferler ve \u00f6zel durumlar d\u0131\u015f\u0131nda agresif m\u00fcdahale edilmemesine ili\u015fkin kan\u0131tlar artmaktad\u0131r. Herkese uymas\u0131 beklenen \u015fablonlarla yakla\u015f\u0131m yanl\u0131\u015f olacakt\u0131r.<\/p>\n

Tablo 1.<\/strong> Ate\u015fin enfeksiy\u00f6z ve non-enfeksiy\u00f6z nedenleri.<\/p>\n

\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
\n

Enfeksiy\u00f6z<\/strong><\/p>\n<\/td>\n

\n

non-enfeksiy\u00f6z<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Sepsis<\/p>\n<\/td>\n

\n

N\u00f6bet\/epilepsi<\/p>\n<\/td>\n<\/tr>\n

\n

Bakteriyel enfeksiyonlar<\/p>\n<\/td>\n

\n

Hipertiroidizm<\/p>\n<\/td>\n<\/tr>\n

\n

-sell\u00fclit<\/p>\n<\/td>\n

\n

N\u00f6roleptik malign sendrom<\/p>\n<\/td>\n<\/tr>\n

\n

-kolesistit\/kolanjit<\/p>\n<\/td>\n

\n

Serotonin sendromu<\/p>\n<\/td>\n<\/tr>\n

\n

-pn\u00f6moni<\/p>\n<\/td>\n

\n

S\u0131cak \u00e7arpmas\u0131<\/p>\n<\/td>\n<\/tr>\n

\n

-osteomiyelit<\/p>\n<\/td>\n

\n

Sempatomimetik kullan\u0131m\u0131<\/p>\n<\/td>\n<\/tr>\n

\n

-idrar yolu enfeksiyonu<\/p>\n<\/td>\n

\n

Antikolinerjik a\u015f\u0131r\u0131 dozu<\/p>\n<\/td>\n<\/tr>\n

\n

-abseler<\/p>\n<\/td>\n

\n

Malign hipertermi<\/p>\n<\/td>\n<\/tr>\n

\n

-menenjit<\/p>\n<\/td>\n

\n

Intrakraniyal hemoraji\/ hematom<\/p>\n<\/td>\n<\/tr>\n

\n

-otit\/sin\u00fczit<\/p>\n<\/td>\n

\n

Maligniteler<\/p>\n<\/td>\n<\/tr>\n

\n

-kardit<\/p>\n<\/td>\n

\n

Otoimm\u00fcn<\/p>\n<\/td>\n<\/tr>\n

\n

Viral enfeksiyonlar<\/p>\n<\/td>\n

\n

Pulmoner embolizm<\/p>\n<\/td>\n<\/tr>\n

\n

Parazitikenfeksiyonlar<\/p>\n<\/td>\n

\n

SVO, tromboz<\/p>\n<\/td>\n<\/tr>\n

\n

Artropod enfeksiyonlar\u0131<\/p>\n<\/td>\n

\n

\u00a0<\/p>\n<\/td>\n<\/tr>\n

\n

Fungal enfeksiyonlar<\/p>\n<\/td>\n

\n

\u00a0<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table><\/div>\n

\u00a0<\/p>\n

Tablo 2.<\/strong> Kan k\u00fclt\u00fcrleri al\u0131nmas\u0131n\u0131n gerekli oldu\u011fu ve olmad\u0131\u011f\u0131 durumlar.<\/p>\n

\n\n\n\n\n\n\n\n\n
\n

\u00a0<\/p>\n<\/td>\n

\n

kan k\u00fclt\u00fcrleri gerekli<\/strong><\/p>\n<\/td>\n

\n

kan k\u00fclt\u00fcrleri gerekli de\u011fil<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Klinik durum\/ampirik tan\u0131<\/strong><\/p>\n<\/td>\n

\n

sepsis<\/p>\n<\/td>\n

\n

sell\u00fclit (y\u00fcz b\u00f6lgesi hari\u00e7)<\/p>\n<\/td>\n<\/tr>\n

\n

menenjit<\/p>\n<\/td>\n

\n

Basit piyelonefrit ve idrar yolu enfeksiyonu<\/p>\n<\/td>\n<\/tr>\n

\n

Komplike piyelonefrit<\/p>\n<\/td>\n

\n

toplum k\u00f6kenli pn\u00f6moni<\/p>\n<\/td>\n<\/tr>\n

\n

endokardit<\/p>\n<\/td>\n

\n

\u00fcst solunum yolu enfeksiyonu<\/p>\n<\/td>\n<\/tr>\n

\n

hastane k\u00f6kenli pn\u00f6moni<\/p>\n<\/td>\n

\n

basit yara enfeksiyonu<\/p>\n<\/td>\n<\/tr>\n

\n

Fasiyal\/periorbital sell\u00fclit<\/p>\n<\/td>\n

\n

\u00a0<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table><\/div>\n

Referanslar<\/h1>\n

1. Morris PE, Promes JT, Guntupalli KK, Wright PE, Arons MM. A multi-center, randomized, double-blind, parallel, placebo controlled trial to evaluate the efficacy, safety, and pharmacokinetics of intravenous ibuprofen for the treatment of fever in critically ill and non-critically ill adults. Crit Care 2010;14: R125.<\/p>\n

2. Azuma A, Kudoh S, Nakashima M, Nagatake T. Antipyretic and analgesic effects of zaltoprofen for the treatment of acute upper respiratory tract infection: verification of a noninferiority hypothesis using loxoprofen sodium. Pharmacology 2011; 87:204\u201313.<\/p>\n

3. Bachert C, Chuchalin AG, Eisebitt R, Netayzhenko VZ, Voelker M. Aspirin compared with acetaminophen in the treatment of fever and other symptoms of upper respiratory tract infection in adults: a multicenter, randomized, double-blind, double-dummy, placebo-controlled, parallel-group, single-dose, 6-hour doseranging study. Clin Ther 2005; 27: 993\u20131003.<\/p>\n

4. Krudsood S, Tangpukdee N, Wilairatana P, Pothipak N, Duangdee C, Warrell DA, et al. Intravenous ibuprofen (IV-ibuprofen) controls fever effectively in adults with acute uncomplicated Plasmodium falciparum malaria but prolongs parasitemia. Am J Trop Med Hyg 2010; 83: 51\u20135.<\/p>\n

5. Tsaganos T, Tseti IK, Tziolos N, Soumelas GS, Koupetori M, Pyrpasopoulou A, et al. Randomized, controlled, multicentre\u00a0clinical trial\u00a0of the antipyretic effect of intravenous paracetamol in patients admitted to hospital with infection. Br J Clin Pharmacol. 2017;83(4):742-750.<\/p>\n

6. Young P, Saxena M, Bellomo R, et al. Acetaminophen for fever in critically ill patients with suspected infection. N Engl J Med 2015;373(23):2215\u201324.<\/p>\n

7. Niven DJ, Gaudet JE, Laupland KB, et al. Accuracy of peripheral thermometers for estimating temperature: a systematic review and meta-analysis. Ann Intern Med 2015; 163(10):768\u201377.<\/p>\n

8. DeWitt\u00a0S, Chavez SA, Perkins J, Long B, Koyfman A. Evaluation of fever in the emergency department. Am J Emerg Med. 2017;35(11):1755-1758.\u00a0<\/p>\n

9. Schuetz P, Muller B, Christ-Cran M, Stolz D, et al. Procalcitonin to initiate or discontinue antibiotics in acute respiratory tract infections. Cochrane Database Syst Rev 2012 Sep 12;9:CD007498.<\/p>\n

10. Pepys MB, Hirschfeld GM. C-reactive protein: a critical update. J Clin Invest 2003;111: 1805\u201312.<\/p>\n

11. Povoa P, Salluh JI. Biomarker-guided antibiotic therapy in adult critically ill patients:a critical review. Ann Intensive Care 2012;2:32.<\/p>\n

12. Lee CC, Hong MY, Lee NY, et al. Pitfalls in using serum C-reactive protein to predict bacteremia in febrile adults in the ED. Am J Emerg Med 2012;30(4):562\u20139.<\/p>\n

13. Povoa P. C-reactive protein: a valuable marker of sepsis. Intensive Care Med 2002;28:235\u201343.<\/p>\n

14. Benenson RS, Kepner AM, Pyle 2nd DN, Cavanaugh S. Selective use of blood cultures in emergency department pneumonia patients. J Emerg Med 2007;33(1):1\u20138.<\/p>\n

15. Long B, Koyfman A. Best Clinical Practice: Blood Culture Utility in the Emergency Department. J Emerg Med. 2016;51(5):529-539.<\/p>\n

16. Kwon JH, Kim JH, Lee JY, Kim YJ, Sohn CH, Lim KS, et al. Low utility of blood culture in pediatric community-acquired pneumonia: An observational study on 2705 patients admitted to the emergency department. Medicine (Baltimore). 2017;96(22):e7028. doi: 10.1097\/MD.0000000000007028.<\/p>\n

17. Neuman MI, Hall M, Lipsett SC, Hersh AL, Williams DJ, Gerber JS, et al; Pediatric Research in Inpatient Settings Network. Utility\u00a0of Blood Culture\u00a0Among Children Hospitalized With Community-Acquired Pneumonia. Pediatrics. 2017;140(3). pii: e20171013. doi: 10.1542\/peds.2017-1013.\u00a0<\/p>\n

18. Saxena M, Young P, Pilcher D, et al. Early temperature and mortality in critically ill patients with acute neurological diseases: trauma and stroke differ from infection.\u00a0Intensive Care Med 2015;41:823-832<\/p>\n

19. Young PJ, Saxena M, Beasley R, et al. Early peak temperature and mortality in critically ill patients with or without infection.\u00a0Intensive Care Med\u00a02012;38:437-444<\/p>\n

20. Spurling GK, Del Mar CB, Dooley L, Foxlee R, Farley R. Delayed antibiotic prescriptions for respiratory infections. Cochrane Database Syst Rev. 2017 Sep 7;9:CD004417. doi: 10.1002\/14651858.CD004417.pub5.\u00a0<\/p>\n

21. The Johns Hopkins Hospital. Antibiotic Guidelines 2015-2016. https:\/\/www.hopkinsmedicine.org\/amp\/guidelines\/Antibiotic_guidelines.pdf. Copyright 2015 by The Johns Hopkins Hospital Antimicrobial Stewardship Program.<\/p>\n

22. El-Nawawy A, Khater D, Omar H, Wali Y. Evaluation of Early Corticosteroid Therapy in Management of Pediatric Septic Shock in Pediatric Intensive Care Patients. Pediatr Infect Dis J. 2017;36(2):155-159.<\/p>\n

23. Hern\u00e1ndez C, Feh\u00e9r C, Soriano A, Marco F, Almela M, Cobos-Trigueros N, et al. Clinical characteristics and outcome of elderly patients with community-onset bacteremia. J Infect. 2015;70(2):135-43.<\/p>\n

24. Fernandes D, Gon\u00e7alves-Pereira J, Janeiro S, et al. Acute bacterial meningitis in the intensive care unit and risk factors for adverse clinical outcomes: retrospective study. J Crit Care 2014;29(3):347\u201350.<\/p>\n

25. Wester AL, Dunlop O, Melby KK, et al. Age-related differences in symptoms, diagnosis and prognosis of bacteremia. BMC Infect Dis 2013;13:346.<\/p>\n

26. Stein PD, Afzal A, Henry JW, et al. Fever in acute pulmonary embolism. Chest 2000; 117(1):39\u201342.<\/p>\n","protected":false},"excerpt":{"rendered":"

Prof. Dr. \u00d6zg\u00fcr Karc\u0131o\u011flu \u0130stanbul EAH, Fatih. Ate\u015f (pireksi) enfeksiyonun en s\u0131k bulgusudur. Enfeksiy\u00f6z veya non-enfeksiy\u00f6z nedenlerle ve v\u00fccudun ate\u015fi tetikleyen maddeye (pirojene) yan\u0131t\u0131 olarak ortaya \u00e7\u0131kar. Hipotalamustan kontrol edilir.…<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"inline_featured_image":false,"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[10011],"tags":[],"class_list":["post-25493","post","type-post","status-publish","format-standard","hentry","category-haber-ve-duyuru"],"acf":[],"_links":{"self":[{"href":"https:\/\/tatd.org.tr\/en\/wp-json\/wp\/v2\/posts\/25493","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/tatd.org.tr\/en\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/tatd.org.tr\/en\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/en\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/en\/wp-json\/wp\/v2\/comments?post=25493"}],"version-history":[{"count":0,"href":"https:\/\/tatd.org.tr\/en\/wp-json\/wp\/v2\/posts\/25493\/revisions"}],"wp:attachment":[{"href":"https:\/\/tatd.org.tr\/en\/wp-json\/wp\/v2\/media?parent=25493"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/tatd.org.tr\/en\/wp-json\/wp\/v2\/categories?post=25493"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/tatd.org.tr\/en\/wp-json\/wp\/v2\/tags?post=25493"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}