Antimicrobial stewardship of β-lactams in intensive care units

Abstract

Stewardship of all antimicrobials, including β-lactam antibiotics, has gained in prominence over the last decade. Appropriate use of these agents has become vitally important; especially in the treatment and management of the critically ill. Opportunities therefore exist to develop innovations to optimise the use of antimicrobials in places like the intensive care unit. The next few years represent an important window in which routine antimicrobial stewardship principles such as surveillance of local ecology, minimising overlap of spectrum of activity and prompt de-escalation upon review of cultures can be integrated with new technologies including improved diagnostic techniques, individualised dosing strategies and computerised decision support. It is important though, that these measures to improve stewardship in the intensive care unit continue to be critically evaluated in the literature.

Keywords::

• antibiotics
• antimicrobial resistance
• β-lactam antibiotics
• critical care unit
• infection
• intensive care unit
• stewardship

Financial & competing interests disclosure

S Blot holds a research mandate of the Special Research Fund at Ghent University. The authors have no other 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 apart from those disclosed.

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

Key issues

• Antimicrobial stewardship in intensive care units targets ideal use of antimicrobial resources.

• This can be achieved through the use of local data on microbial ecology, avoidance of agents with overlapping spectrum of activity, adjusting therapy when culture results become available, optimizing doses, route of administration and duration of therapy.

• Hospital-wide initiatives to restrict the use of broad-spectrum antimicrobial agents can be successful to reduce overall consumption of such agents as well as the prevalence of multidrug-resistant pathogens.

• Use of antibiograms with clinical breakpoints allows physicians to select agents with the highest likelihood of clinical success.

• Routine surveillance cultures provide detailed insight in local microbial ecology and can be used to steer empirical therapy. Because of its high negative predictive value, this approach allows limited use of last-line antimicrobials upfront.

• De-escalation of empirical therapy to narrower spectrum agents appears to be safe and allows shortening the duration of initially administered broad-spectrum agents.

• Therapeutic drug monitoring for dose optimization should be considered a valuable intervention to increase the chances of pharmacokinetic/pharmacodynamic target attainment.