Escalation Introduction • Effective antimicrobial therapy is critical for the treatment of patients in the intensive care unit (ICU), including patients admitted with severe sepsis, septic shock, and those who develop health-care-associated infections • Delays in appropriate antimi- crobial therapy worsen outcomes in critically ill patients • Multidrug-resistant organisms are increasingly common and are associated with a longer length of stay, ICU admission, and higher mortality rates • Initiating effective therapy for infections based upon patients’ risk factors, collection of appropriate cultures, daily evaluation of clinical status, and laboratory data, including antibiotic time outs, and shortened durations of therapy are ways to improve patient out- comes • Special attention should be paid to the dosing of antimicrobials in the ICU, as fluctuations in fluid status, organ function, and perfusion can affect antibiotic pharmacokinetics and therefore antibiotic efficacy at the site of infection • This analitic reviews the most recent evidence supporting empiric antibiotic selection, de- escalation strategies, the importance of optimized antimicrobial doses, and antimicro- bial stewardships role in the ICU •Select antibiotics based upon national guidelines and local susceptibilities •Patient specific factors (immunosuppression, indwelling catheters, Optimization Initiate allergies) •Common pathogens for suspected source
•Daily review of clinical signs and symptoms of infection
Utilize •Review of cultures and molecular diagnostics pharmacokinetic/ Evaluate •Analyze current dosing strategy pharmacodynamic principles to increase cidality
•Narrow therapy based upon cultures and to
minimize adverse events Antimicrobial De-escalate •Consider shorter durations based upon clinical status Stewardship