Bloodstream infections in the Intensive Care Unit

Figures & data

Table 1. Risk factors for BSIs due to MDR pathogens.

– Local outbreaks of MDR and local epidemiology (high risk if resistance is reported in > 20% of isolates) – Previous colonization with MDR pathogens – Exposure to broad-spectrum antimicrobial agents (in particular fluo roquinolones and/or third-generation cephalosporins and/or carbapenems) within 30 days – Admission to ICU – Mechanical ventilation – Devices placement (central venous catheter or other intravascular devices, urinary catheter) – Health-care associated or hospital-acquired infections – Recent surgery or invasive procedures within 30 days – Underlying severity of illness (Charlson index of ≥3) – Neutropenia (<500 PMN/mm^3)

Table 2. suggested dosages of the most common antimicrobials used for the treatment of BSIs in critically ill patients.

Antimicrobial	Dose
Ceftazidime	15 mg/kg loading dose, then 6-8 g every 24 h c.i.
Cefepime	15 mg/kg loading dose, then 2 g every 8 h c.i.
Piperacillin/tazobactam	4.5 g (loading dose), then 18 g every 24 h c.i.
Meropenem	1-2 g every 8 h e.i.
Ertapenem	1 g every 12 h
Amikacin	25-30 mg/kg every 24 h
Gentamicin	7 mg/kg every 24 h
Vancomycin	1 g loading dose, then 30 mg/kg every 24 h c.i.
Daptomycin	8-10 mg/kg every 24 h
Tigecycline	100-200 mg (loading dose), then 50-100 mg every 12 h
Colistin	9 MU loading dose, 4.5 MU every 12 h
RifampinFosfomycin	600-900 mg every 24 h4-6 g every 6 h c.i.
Caspofungin	70 mg, then 50 mg every 24 h
Anidulafungin	200 mg, then 100 mg every 24 h
Micafungin	100 mg every 24 h

Notes. c.i.: continuous infusion

e.i: extended infusion (6-8 hours)

Table 3. Possible strategies for de-escalation in BSIs.

Pathogen	Antimicrobial options
MSSA or MSSE	Oxacillin (12-16 g every 24 h c.i.) or cefazolin (2-4 g every 8 h c.i)
Streptococci	Ampicillin (2 g every 4 h c.i.) or ceftriaxone (2 g every 24 h)
Enterococcus faecalis	Ampicillin (2 g every 4 h c.i.)
Non-ESBL Enterobacteriacae	Ceftriaxone (2 g every 24 h)
ESBL-Enterobacteriacae	Ertapenem (500 mg every 6 h, e.i. 4 h) )
Susceptible P.aeruginosa	Piperacillin-tazobactam (4.5 g loading dose, then 18g q 24h c.i.) or antipseudomonal cephalosporin (ceftazidime 6 g every 24 h, c.i.or cefepime 6 g every 24 hours, c.i.)
Fluconazole-susceptible Candida spp	Fluconazole (loading dose 12 mg/kg every 12 h, then 400 mg every 24 h)

Notes. MSSA: methicillin-susceptible Staphylococcus aureus

MSSE: methicillin-susceptible Staphylococcus epidermidis

Figure 1. Treatment algorithm for empirical therapy of staphylococcal BSI