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Rationalizing antimicrobial therapy in the ICU : a narrative review

(2019) INTENSIVE CARE MEDICINE. 45(2). p.172-189
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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.
Keywords
Antibiotic stewardship, Antimicrobial resistance, Empirical therapy, Critical illness, Carbapenem, Outcome, Sepsis, VENTILATOR-ASSOCIATED PNEUMONIA, INTENSIVE-CARE-UNIT, RESISTANT ACINETOBACTER-BAUMANNII, BLOOD-STREAM INFECTIONS, CRITICALLY-ILL PATIENTS, AMPC-HYPERPRODUCING ENTEROBACTERIACEAE, LACTAMASE-PRODUCING ENTEROBACTERIACEAE, STAPHYLOCOCCUS-AUREUS BACTEREMIA, COURSE ANTIBIOTIC-THERAPY, GRAM-NEGATIVE BACTERIA

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Citation

Please use this url to cite or link to this publication:

Chicago
Timsit, Jean-François, Matteo Bassetti, Olaf Cremer, George Daikos, Jan De Waele, Andre Kallil, Eric Kipnis, et al. 2019. “Rationalizing Antimicrobial Therapy in the ICU : a Narrative Review.” Intensive Care Medicine 45 (2): 172–189.
APA
Timsit, J.-F., Bassetti, M., Cremer, O., Daikos, G., De Waele, J., Kallil, A., Kipnis, E., et al. (2019). Rationalizing antimicrobial therapy in the ICU : a narrative review. INTENSIVE CARE MEDICINE, 45(2), 172–189.
Vancouver
1.
Timsit J-F, Bassetti M, Cremer O, Daikos G, De Waele J, Kallil A, et al. Rationalizing antimicrobial therapy in the ICU : a narrative review. INTENSIVE CARE MEDICINE. 2019;45(2):172–89.
MLA
Timsit, Jean-François et al. “Rationalizing Antimicrobial Therapy in the ICU : a Narrative Review.” INTENSIVE CARE MEDICINE 45.2 (2019): 172–189. Print.
@article{8589765,
  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.},
  author       = {Timsit, Jean-Fran\c{c}ois and Bassetti, Matteo and Cremer, Olaf and Daikos, George and De Waele, Jan and Kallil, Andre and Kipnis, Eric and Kollef, Marin and Laupland, Kevin and Paiva, Jose-Artur and Rodr{\'i}guez-Ba{\~n}o, Jes{\'u}s and Rupp{\'e}, {\'E}tienne and Salluh, Jorge and Taccone, Fabio Silvio and Weiss, Emmanuel and Barbier, Fran\c{c}ois},
  issn         = {0342-4642},
  journal      = {INTENSIVE CARE MEDICINE},
  language     = {eng},
  number       = {2},
  pages        = {172--189},
  title        = {Rationalizing antimicrobial therapy in the ICU : a narrative review},
  url          = {http://dx.doi.org/10.1007/s00134-019-05520-5},
  volume       = {45},
  year         = {2019},
}

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