Table 1 Analogy between the 4 Ds of antibiotic and fluid therapy Stewardship.
Description | Antibiotics | Fluids | |
|---|---|---|---|
Drug | Inappropriate therapy | More organ failure, longer ICU/hospital length of stay, longer duration mechanical ventilation (MV) | Hyperchloremic metabolic acidosis, more acute kidney injury, more need for renal replacement therapy, increased mortality |
Appropriate therapy | Key factor in empiric AB choice is consideration of patient risk factors (prior AB use, duration of mechanical ventilation, corticosteroids, recent hospitalization, residence in nursing home, etc.) | Key factor in empiric fluid therapy is consideration of patient risk factors (fluid balance, fluid overload, capillary leak, source control, kidney function, organ function). Do not use glucose as a resuscitation fluid | |
Combination therapy | Possible benefits: broader spectrum, synergy, avoidance of emergency of resistance, less toxicity | Possible benefits: specific fluids for different indications (replacement vs maintenance vs resuscitation), less toxicity | |
Appropriate timing | Survival decreases with 7% per hour delay. Needs discipline and practical organization | In refractory shock early goal-directed therapy (EGDT) has proven beneficial. The longer the delay, the more microcirculatory hypoperfusion | |
Dosing | Pharmacokinetics | Depends on distribution volume, clearance (kidney and liver function), albumin level, tissue penetration | Depends on type of fluid: glucose remains 10% intravascular, crystalloids 25%, vs colloids 100% after 1 h, and other factors (distribution volume, osmolality, oncoticity, kidney function) |
Pharmacodynamics | Reflected by the minimal inhibitory concentration. Reflected by “kill” characteristics, time (T > MIC) vs concentration (Cmax/MIC) dependent | Depends on type of fluid and where you want them to go: intravascular (resuscitation), interstitial vs intracellular (cellular dehydration) | |
Toxicity | Some ABs are toxic for kidneys, advice on dose adjustment needed. However, not getting infection under control is not helping the kidneys either | Some fluids (HES—starches) are toxic for the kidneys. However, not getting shock under control is not helping the kidneys either | |
Duration | Appropriate duration | No strong evidence but trend toward shorter duration. Do not use ABs to treat fever, CRP, infiltrates, but use ABs to treat infections | No strong evidence but trend toward shorter duration. Do not use fluids to treat low central venous or mean arterial pressure, urine output, but use fluids to treat hypovolemia |
Treat to response | Stop ABs when signs and symptoms of active infection resolve. Future role for biomarkers (PCT) | Fluids can be stopped when shock is resolved (normal lactate). Future role for biomarkers (NGAL, cystatin C, citrullin, L-FABP) | |
De-escalation | Monitoring | Take cultures first and have the guts to change a winning team | After stabilization with early adequate fluid management (normal PPV, normal cardiac output, normal lactate), stop ongoing resuscitation and move to conservative late fluid management and late goal-directed fluid removal (= deresuscitation) |