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Antibiotic resistance is a major and growing problem, and antimicrobials are a limited resource. Antimicrobial stewardship is an approach to improving and monitoring the use of existing antimicrobials.
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The intensive care unit (ICU) is a unique and high-stakes setting for antimicrobial use that presents distinct challenges for antimicrobial stewardship programs. This article outlines approaches to antimicrobial stewardship with a focus on the ICU setting.
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Opportunities for antimicrobial
Antimicrobial Stewardship Approaches in the Intensive Care Unit
Section snippets
Key points
Case presentations
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A 75-year-old man who underwent a Whipple procedure for pancreatic cancer 1 month prior with a rocky postoperative course, including respiratory failure, shock, upper gastrointestinal bleed, and surgical site infection, develops a new fever, need for reintubation, and pressor requirement. Blood and urine cultures are negative and chest radiograph demonstrates bilateral infiltrates, stable from prior. How should this patient's antibiotics be managed initially? What tests are useful to help
Background
More than 2 million illnesses and 23,000 deaths occur each year in the United States due to infections caused by antimicrobial-resistant pathogens, a large burden of which occur in the intensive care unit (ICU) setting.1, 2 Since the discovery of penicillin, there has been a clear temporal relationship between the introduction of antibiotics into clinical practice and development of resistance.3 Though the antibiotic pipeline has improved in recent years, new drugs have not kept pace with
General antimicrobial stewardship approaches
Basic elements of antimicrobial stewardship programs (ASPs) include having a dedicated institutional policy, an interdisciplinary team, members (ideally both MD and PharmD degrees) with training in antimicrobial stewardship or ID, and monitoring and reporting of activities (Fig. 1). Core actions of ASPs include7, 8
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Facility-specific guidelines based on national guidelines, local antibiogram, and formulary availability. These can be for particular syndromes such as pneumonia, individual
Diagnosis
As a corollary to the common use of inappropriate antimicrobial therapy in the ICU setting for noninfectious or nonbacterial syndromes, or treatment of colonization or contamination, more accurate and timely diagnosis of infection should result in improved antimicrobial use.18, 19 Goals of diagnostics for infection include
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Establishing an infection as the cause of the presenting syndrome; discrimination of bacterial infection from noninfectious syndrome
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Discrimination of bacterial from
Empirical therapy
While awaiting results of a work-up for a suspected infection, antimicrobial therapy will likely be administered to the ICU patient. Because inadequate empirical antibiotic therapy, or empirical antibiotics that do not cover the ultimate identified pathogen, accounts for an estimated 39% to 51% of excess mortality in ICU patients with various infectious syndromes, initiation of broad empirical therapy in a patient with high suspicion for infection is appropriate.15, 16, 63, 64 However,
Definitive therapy
Once the patient has been stabilized with empirical antimicrobials and diagnostic testing results return, a clinical and/or microbiological diagnosis often, though not always, can be made. At this point, goals of therapy become
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Choosing the narrowest and most potent agent for identifying the syndrome and microbes and treating for minimal effectiveness
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Optimizing pharmacodynamics and pharmacokinetics
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Avoiding adverse consequences of antimicrobial use while ensuring cure of infection.
Demonstrating effectiveness
As with any quality improvement program, ASPs must track outcomes to focus efforts, demonstrate successes, and ensure no unexpected countermeasures. In general, ASPs should monitor both process and outcome measures.7 This includes measures of antimicrobial usage (eg, days of therapy) normalized to census, costs, antibiotic resistance, uptake of recommendations, and clinical outcomes such as adverse events, secondary infections, mortality, and length-of-stay.
Summary
Antimicrobial stewardship in the ICU setting can improve quality of care and decrease antimicrobial resistance without compromising patient outcomes. Though low-level evidence supports individual aspects of stewardship, there is little information about which particular interventions have the most impact.133 Two structured reviews of antimicrobial stewardship in the ICU setting have found modest benefit, though studies tend to be small and uncontrolled, with lack of emphasis on patient-centered
References (134)
- et al.
Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients
Chest
(1999) - et al.
ICU antimicrobial stewardship (AMS) rounds: the daily activities of an AMS service
Int J Antimicrob Agents
(2016) - et al.
Impact of infectious diseases team consultation on antimicrobial use, length of stay and mortality
Am J Med Sci
(2015) - et al.
Effect of procalcitonin testing on healthcare utilization and costs in critically ill patients in the United States
Chest
(2017) - et al.
Accuracy of clinical definitions of ventilator-associated pneumonia: comparison with autopsy findings
J Crit Care
(2010) - et al.
Utility of gram stain in the clinical management of suspected ventilator-associated pneumonia: secondary analysis of a multicenter randomized trial
J Crit Care
(2008) - et al.
A negative urinalysis rules out catheter-associated urinary tract infection in trauma patients in the intensive care unit
J Am Coll Surg
(2013) - et al.
Restrictive reporting of selected antimicrobial susceptibilities influences clinical prescribing
J Infect Public Health
(2015) - et al.
Integrating rapid diagnostics and antimicrobial stewardship improves outcomes in patients with antibiotic-resistant gram-negative bacteremia
J Infect
(2014) - et al.
Impact of BAL data on the therapy and outcome of ventilator-associated pneumonia
Chest
(1997)
The influence of inadequate antimicrobial treatment of bloodstream infections on patient outcomes in the ICU setting
Chest
The past, present, and future of the centers for Medicare and Medicaid services quality measure SEP-1: the early management bundle for severe sepsis/septic shock
Emerg Med Clin North Am
Antifungal therapy for patients with proven or suspected candida peritonitis: Amarcand2, a prospective cohort study in French intensive care units
Clin Microbiol Infect
The TREAT project: Decision support and prediction using causal probabilistic networks
Int J Antimicrob Agents
Impact of a computerized clinical decision support system on reducing inappropriate antimicrobial use: a randomized controlled trial
J Am Med Inform Assoc
Health care use and serious infection prevalence associated with penicillin “allergy” in hospitalized patients: a cohort study
J Allergy Clin Immunol
Consequences of avoiding β-lactams in patients with β-lactam allergies
J Allergy Clin Immunol
Fatal anaphylaxis in the united states 1999-2010: temporal patterns and demographic associations
J Allergy Clin Immunol
A pilot study of penicillin skin testing in patients with a history of penicillin allergy admitted to a medical ICU
Chest
Epidemiology and control of antibiotic resistance in the intensive care unit
Curr Opin Infect Dis
Humans as the world's greatest evolutionary force
Science
Implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America
Clin Infect Dis
Effects of monitoring the usage of antibiotics: an interhospital comparison
South Med J
Usage of antibiotics in a general hospital: Effect of requiring justification
J Infect Dis
Medicare and Medicaid programs; hospital and critical access hospital (CAH) changes to promote innovation, flexibility, and improvement in patient care; proposed rule
Fed Regist
Hospital and societal costs of antimicrobial-resistant infections in a Chicago teaching hospital: implications for antibiotic stewardship
Clin Infect Dis
Impact of inadequate initial antimicrobial therapy on mortality in infections due to extended-spectrum beta-lactamase-producing enterobacteriaceae: variability by site of infection
Arch Intern Med
Empirical antimicrobial therapy of septic shock patients: adequacy and impact on the outcome
Crit Care Med
Predictors of mortality in patients with bloodstream infections caused by extended-spectrum-{beta}-lactamase-producing Enterobacteriaceae: importance of inadequate initial antimicrobial treatment
Antimicrob Agents Chemother
Different patterns of inappropriate antimicrobial use in surgical and medical units at a tertiary care hospital in Switzerland: a prevalence survey
PLoS One
Unnecessary use of antimicrobials in hospitalized patients: current patterns of misuse with an emphasis on the antianaerobic spectrum of activity
Arch Intern Med
Antibiotic prescribing decisions of generalists and infectious disease specialists: thresholds for adopting new drug therapies
Med Decis Making
Influence of an infectious diseases specialist on ICU multidisciplinary rounds
Crit Care Res Pract
Using procalcitonin-guided algorithms to improve antimicrobial therapy in ICU patients with respiratory infections and sepsis
Curr Opin Crit Care
Integrative “Omic” analysis of experimental bacteremia identifies a metabolic signature that distinguishes human sepsis from systemic inflammatory response syndromes
Am J Respir Crit Care Med
Identification of sepsis subtypes in critically ill adults using gene expression profiling
Crit Care
A molecular host response assay to discriminate between sepsis and infection-negative systemic inflammation in critically ill patients: discovery and validation in independent cohorts
PLoS Med
A host-based RT-PCR gene expression signature to identify acute respiratory viral infection
Sci Transl Med
Clinical diagnosis of ventilator associated pneumonia revisited: comparative validation using immediate post-mortem lung biopsies
Thorax
Does this patient have ventilator-associated pneumonia?
JAMA
Diagnosis of ventilator-associated pneumonia by bacteriologic analysis of bronchoscopic and nonbronchoscopic “blind” bronchoalveolar lavage fluid
Am Rev Respir Dis
Ventilator-associated pneumonia: the clinical pulmonary infection score as a surrogate for diagnostics and outcome
Clin Infect Dis
Diagnosing pneumonia during mechanical ventilation: the clinical pulmonary infection score revisited
Am J Respir Crit Care Med
Short-course empiric antibiotic therapy for patients with pulmonary infiltrates in the intensive care unit. A proposed solution for indiscriminate antibiotic prescription
Am J Respir Crit Care Med
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Disclosure Statement: SBD has received research funding from Merck, Genentech, Cerexa, and Cubist Pharmaceuticals and serves as a consultant to Actelion. HFC has received grant support from Allergan and Genentech.