The intensive care medicine research agenda on multidrug-resistant bacteria, antibiotics, and stewardship

Abstract

Purpose: To concisely describe the current standards of care, major recent advances, common beliefs that have been contradicted by recent trials, areas of uncertainty, and clinical studies that need to be performed over the next decade and their expected outcomes with regard to the management of multidrug-resistant (MDR) bacteria, antibiotic use, and antimicrobial stewardship in the intensive care unit (ICU) setting. Methods: Narrative review based on a systematic analysis of the medical literature, national and international guidelines, and expert opinion. Results: The prevalence of infection of critically ill patients by MDR bacteria is rapidly evolving. Clinical studies aimed at improving understanding of the changing patterns of these infections in ICUs are urgently needed. Ideal antibiotic utilization is another area of uncertainty requiring additional investigations aimed at better understanding of dose optimization, duration of therapy, use of combination treatment, aerosolized antibiotics, and the integration of rapid diagnostics as a guide for treatment. Moreover, there is an imperative need to develop non-antibiotic approaches for the prevention and treatment of MDR infections in the ICU. Finally, clinical research aimed at demonstrating the beneficial impact of antimicrobial stewardship in the ICU setting is essential. Conclusions: These and other fundamental questions need to be addressed over the next decade in order to better understand how to prevent, diagnose, and treat MDR bacterial infections. Clinical studies described in this research agenda provide a template and set priorities for investigations that should be performed in this field.

Carbapenem-Nonsusceptible Gram-Negative Pathogens in ICU and Non-ICU Settings in US Hospitals in 2017: A Multicenter Study

“…Increasing resistance to carbapanems thus jeopardizes patient outcomes and results in a significant economic burden [2, 3]. The increased morbidity and mortality associated with antibiotic resistance is of particular concern in vulnerable populations such as patients in intensive care units (ICUs) [4]. In recognition of this critical risk to public health, the Centers for Disease Control and Prevention has identified carbapenem-resistant Enterobacteriaceae (CRE) as an urgent threat [5], and the World Health Organization has prioritized the development of antibiotics against CRE and carbapenem-resistant Acinetobacter baumannii and Pseudomonas aeruginosa [6].…”

Performance and impact of a multiplex PCR in ICU patients with ventilator-associated pneumonia or ventilated hospital-acquired pneumonia

“…4 HAP and VAP may be caused by a wide variety of pathogens and can be polymicrobial. 7,8 Moreover, multidrug-resistant (MDR) and extensively drug-resistant (XDR) bacteria, especially Gram-negative bacilli, are increasingly frequently isolated in HAP and VAP and are associated with mortality rates over 50%. 9 Early appropriate antibiotic therapy undoubtedly reduces morbidity and mortality of HAP and VAP but these infections are responsible for up to half of the consumption of antibiotics in ICU.…”

Focus on sepsis: new concepts and findings in sepsis care

“…The control of MDRB requires antibiotic stewardship programs that should include faster diagnostic spanning antibiotic resistance, in addition to pathogen identification, and a better assessment of pharmacokinetics parameters. New antibiotics active on MDRB (especially Gram-negative rods) are also urgently needed [15].…”