The management of anti-infective agents in intensive care units: the potential role of a ‘fast’ pharmacology

ABSTRACT

Introduction

Patients in intensive care units (ICU) are often developing severe infections in which are associated with significant mortality rates. A number of novel technologies for the rapid microbiological diagnosis of these infections have been developed, introducing the era of ‘fast microbiology.’ Treatment of bacterial and fungal infections in ICU is however complicated by alterations in the pharmacokinetics of antimicrobial agents.

Areas covered

We review novel pharmacologic tools that can be used to optimize anti-infective therapies and patient management in ICU. A MEDLINE Pubmed search for articles published from January 1995 to 2019 was completed matching the terms pharmacokinetics and pharmacology with antimicrobial agents and ICU or critically ill patients. Moreover, additional studies were identified from the reference list of retrieved articles.

Expert opinion

Several tools are in development for the full automation of the analytical methods used for the quantification of antimicrobial concentrations within a few hours after sample collection. Ad hoc software with adaptive feedback is also available for appropriate dose adjustments based on both individual patient covariate data and therapeutic drug monitoring (TDM) data when available. The application of these technological improvements in the clinical practice should open the way to a ‘fast pharmacology’ at the bedside.

KEYWORDS:

• Critically ill patients
• anti-infective agents
• fast pharmacology
• drug management

Article highlights

• Patients in intensive care units (ICU) are often developing severe infections in which are associated with significant mortality rates.

• In recent years, a number of novel technologies for the microbiological diagnosis of infections that provide results in a shorter time frame when compared with conventional diagnostic approaches have been developed, opening the era of fast microbiology.

• Treatment of bacterial and fungal infections in ICU is however complicated by alterations in the pharmacokinetics of antimicrobial agents.

• Successful treatment of severe infections in ICU is based on a proper antimicrobial stewardship program which should include the selection of the most appropriate antimicrobial agent(s) and ensuring adequate exposure whilst taking into consideration both the pathophysiologic changes of ICU patients and the physicochemical properties of the antimicrobial agent(s) administered to reach optimal pharmacokinetic/pharmacodynamic (PK/PD) targets.

• Prospective clinical trials are required to determine whether a fast pharmacology-based approach (ideally combined with a fast microbiology to reach PK/PD targets) can significantly improve the treatment of infections in ICU patients.

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.