Strategies for implementation of a multidisciplinary approach to the treatment of nosocomial infections in critically ill patients

ABSTRACT

Introduction

Intensive Care Units (ICU) are among the hospital wards exhibiting the highest prevalence of antimicrobial resistance (AMR), and resulting impact on patient outcomes. Antimicrobial resistance surveillance and antimicrobial stewardship (AMS) programs play a pivotal role in promoting interventions tailored to optimize infection diagnosis and treatment in the final attempt to limit unnecessary antimicrobial use and development of resistance.

Areas covered

A narrative review of the literature was carried out to summarize the available evidence and develop a set of actions that should be considered for integration into the ICU stewardship framework. Four questions were addressed: how AMR surveillance can inform antibiotic policy in ICU; whether pharmacokinetic and pharmacodynamic (PK/PD) principles and the use of procalcitonin should be incorporated as a standard practice in ICU AMS programs to optimize antibiotic treatment and to drive antibiotic discontinuation; which criteria should drive treatment duration of ICU-associated infections.

Expert opinion

In this review we aim to highlight that the ICU must be considered in its own right. Each ICU has its own characteristics depending on the country, on the local antibiotic resistance profile, on the patients feature and the severity of infection.

KEYWORDS:

• Sepsis
• pneumonia
• VAP
• VAT
• PK/PD
• ICU

Acknowledgment

The authors would like to thank Nithya Babu Rajendran and Evelina Tacconelli for providing information on European surveillance systems derived from the COMBACTE-MAGNET EPI-Net project’s surveillance repository (epi-net.eu).

Article highlights

• Intensive Care Units (ICU) are among the hospital wards exhibiting the greatest prevalence of antimicrobial resistance (AMR) with a relevant clinical impact on patient’s outcomes

• Antimicrobial stewardship (AMS) programs play a pivotal role in implementing a multidisciplinary approach with the aim to design interventions tailored to optimize infection diagnosis and treatment in the attempt to limit unnecessary antimicrobial use and related side effects

• AMR surveillance represents the keystone for infection control measures, stewardship interventions, and for the development of protocols for empirical antibiotic therapy

• Therapeutic drug monitoring (TDM) is useful for dose adjustments but its use across ICUs is heterogeneous and often not considered, despite a growing body of supportive evidence, of TDM as a guide for dose optimization, especially for beta-lactams.

• The use of procalcitonin measurement supports clinical decisions and antibiotic management, specifically to facilitate earlier discontinuation of antibiotics

Declaration of interest

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.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.