Rationalizing antimicrobial therapy in the ICU: a narrative review

Jean François Timsit, Matteo Bassetti, Olaf Cremer, George Daikos, Jan de Waele, Andre Kallil, Eric Kipnis, Marin Kollef, Kevin Laupland, Jose Artur Paiva, Jesús Rodríguez-Baño, Étienne Ruppé, Jorge Salluh, Fabio Silvio Taccone, Emmanuel Weiss, François Barbier

Research output: Contribution to journalReview articlepeer-review

83 Scopus citations

Abstract

The massive consumption of antibiotics in the ICU is responsible for substantial ecological side effects that promote the dissemination of multidrug-resistant bacteria (MDRB) in this environment. Strikingly, up to half of ICU patients receiving empirical antibiotic therapy have no definitively confirmed infection, while de-escalation and shortened treatment duration are insufficiently considered in those with documented sepsis, highlighting the potential benefit of implementing antibiotic stewardship programs (ASP) and other quality improvement initiatives. The objective of this narrative review is to summarize the available evidence, emerging options, and unsolved controversies for the optimization of antibiotic therapy in the ICU. Published data notably support the need for better identification of patients at risk of MDRB infection, more accurate diagnostic tools enabling a rule-in/rule-out approach for bacterial sepsis, an individualized reasoning for the selection of single-drug or combination empirical regimen, the use of adequate dosing and administration schemes to ensure the attainment of pharmacokinetics/pharmacodynamics targets, concomitant source control when appropriate, and a systematic reappraisal of initial therapy in an attempt to minimize collateral damage on commensal ecosystems through de-escalation and treatment-shortening whenever conceivable. This narrative review also aims at compiling arguments for the elaboration of actionable ASP in the ICU, including improved patient outcomes and a reduction in antibiotic-related selection pressure that may help to control the dissemination of MDRB in this healthcare setting.

Original languageEnglish
Pages (from-to)172-189
Number of pages18
JournalIntensive care medicine
Volume45
Issue number2
DOIs
StatePublished - Feb 27 2019

Keywords

  • Antibiotic stewardship
  • Antimicrobial resistance
  • Carbapenem
  • Critical illness
  • Empirical therapy
  • Outcome
  • Sepsis

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