Shortening the course of antibiotic treatment in the intensive care unit

Abstract

Effective antimicrobial stewardship is an increasingly important concern for healthcare providers globally. Antibiotics are frequently prescribed for patients who develop sepsis in the intensive care unit and traditionally courses are prolonged, with uncertain benefit and probable harm. There is little evidence to support many guidelines recommending between 10 and 14 days, and a number of studies suggest substantially shorter courses of less than 7 days may suffice. Safely reducing course length is likely to depend on a number of preconditions, including thorough eradication of any septic foci; optimization of serum antibiotic concentrations, particularly when there is physiological derangement; and use of novel biomarkers such as procalcitonin. The critical care environment is well suited to this aim as patients are closely monitored. With these measures in place, it is reasonable to believe short antibiotic courses can safely be used for the majority of intensive care infections.

Keywords:

• antibiotic
• bloodstream infection
• critical illness
• intensive care
• pharmacokinetics
• reducing course length
• ventilator-associated pneumonia

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• There is little evidence to support current recommendations for antibiotic course length in critically ill patients.

• Prolonged antibiotic courses are expensive, and may cause harm to both the patient and the population as a whole.

• A number of studies have demonstrated equivalent safety and efficacy for shorter course lengths for infections including ventilator-associated pneumonia, bloodstream infection and abdominal infections.

• For antibiotic course lengths to be reduced without compromising patient care, effective control of the source of sepsis must be achieved.

• Therapeutic drug monitoring, dose adjustments to account for the altered pharmacokinetics observed in critically ill patients and biomarker monitoring may also be useful.