Principles and Practice of Antibiotic Stewardship in the ICU

Abstract

In the face of emerging drug-resistant pathogens and a decrease in the development of new antimicrobial agents, antibiotic stewardship should be practiced in all critical care units. Antibiotic stewardship should be a core competency of all critical care practitioners in conjunction with a formal antibiotic stewardship program (ASP). Prospective audit and feedback, and antibiotic time-outs, are effective components of an ASP in the ICU. As rapid diagnostics are introduced in the ICU, assessment of performance and effect on outcomes will clearly be needed. Disease-specific stewardship for community-acquired pneumonia that relies on clinical pathways may be particularly high-yield. Computerized decision support has the potential to individualize stewardship for specific patients. Finally, infection control and prevention is the cornerstone of every ASP.

Novel Approaches to Hasten Detection of Pathogens and Antimicrobial Resistance in the Intensive Care Unit

“…RDTs hold promise for minimizing unnecessary antibiotic exposure in critically ill patients while maximizing patient outcomes with appropriate antibiotic administration. 48,49 Selection and implementation of RDTs is not an easy task. To validate new technologies, a gold standard should be available, but this may not always be the case in microbiology.…”

A multiplex polymerase chain reaction assay for antibiotic stewardship in suspected pneumonia

“…Moreover, empirical treatment of both CAP and HAP/VAP focuses on MRSA and Pseudomonas coverage. ( Kalil et al, 2016 ) Subsequent tailoring of antibiotics is recommended to treat the specific etiology depending on the microbiological diagnosis; ( Pickens and Wunderink, 2019 ) however, the turnaround time for a final respiratory culture result can be upwards of 72 hours, during which time patients continue to receive empirical antibiotics. In addition, respiratory cultures are often negative due to their relatively poor sensitivity, particularly when obtained after initiation of antibiotic therapy, and can miss important pathogens when concealed by the growth of multiple organisms in culture.…”

Updates on community acquired pneumonia management in the ICU

“…Use of antibiotics such as macrolides, beta-lactams, and quinolones, prior to admission to the ICU is a well-known predisposing factor for subsequent resistance to the same class of antibiotic particularly for Pneumococcus( Clavo-Sanchez et al, 1997 ; Ho et al, 2001 ; Ruhe and Hasbun, 2003 ; Vanderkooi, Low, Green, Powis, and McGeer, 2005 ). Part of the issue is lack of newer antibiotics to keep up with the emergence of resistance to other classes or earlier generations of antibiotics( Pickens and Wunderink, 2019 ). Recognizing the importance of curbing antimicrobial resistance, in 2014 White House released a Presidential Executive Order 13676 for Combating Antibiotic-Resistant Bacteria (CARB)( Pickens and Wunderink, 2019 ).…”