Table 4 Bedside principles for optimizing antibiotic prescribing in the ICU
From: Antibiotic stewardship in the ICU: time to shift into overdrive
Carry out a thorough clinical examination with oriented imaging ± whole-body CT scan Use invasive diagnostic tools, especially if the patient is severe on admission. Microbiological sampling is mandatory prior administering antibiotic |
If septic shock is suspected, use broad-spectrum combination therapy within one hour |
Without shock, if a potential source of infection is identified, use monotherapy unless specific recommendation (e.g., community-acquired pneumonia) |
Without shock, if sepsis is suspected and no source of infection identified, withhold antimicrobial treatment. Search for differential diagnosis |
Empiric antibiotic therapy should be selected based on identified source and local ecology Limit the use of carbapenems to patients with a high likelihood of ESBL infection. Use of rectal or respiratory ESBL colonization may be useful |
Systematically reassess antibiotic therapy after 48Â h |
De-escalation should be done as early as possible. For early de-escalation, ESBL-chromogenic tests may be useful |
In the absence of documentation after 48Â h, search for a differential diagnosis |
In most cases, the definitive treatment should be a monotherapy. Combination therapy can be discussed for difficult-to-treat pathogens or specific localizations (endocarditis, prosthetic device infection, joint and bone infection, abscess) |
Use prolonged beta-lactam infusion after initial loading dose in severe patients (e.g., shock) |
TDM is recommended for aminoglycosides and vancomycin, and in general for antibiotics having narrow therapeutic window or suspected drug toxicity Beta-lactams TDM should be used for prolonged therapy and in specific situations (augmented renal clearance, renal replacement therapy, ECMO) |
Use short-course (7-day) for most of infections. PCT may be useful to help shorten the duration of antimicrobial treatment |