Maximizing rates of empiric appropriate antibiotic therapy with minimized use of broad-spectrum agents: are surveillance cultures the key?

Excerpt

Of the many therapeutic decisions, physicians have to face in daily ICU practice choosing initial antibiotic therapy in the patient with suspected severe nosocomial sepsis is one of the more challenging. To favourably impact the outcome, antibiotic therapy covering the offending pathogen has to be initiated without delay [1, 2], which implies administration within 24 h of clinical deterioration and within 1 h of septic shock. This therapeutic choice is little supported by the microbiology lab, as microbiological identification and susceptibility testing usually require 48 h. In patients at risk for infection with multidrug resistant (MDR) pathogens, the clinician has to resort to broad-spectrum antimicrobials, which are themselves linked with the emergence of multidrug resistance. In this respect, appropriate empirical antibiotic therapy should have a balanced antimicrobial spectrum that includes the susceptibility of the infectious pathogen, but does not add unnecessary selection pressure. As the prevalence and complexity of MDR patterns steadily rise, finding this balance is increasingly difficult. Therefore the empirical use of broad-spectrum antibiotic drugs in patients at risk for MDR pathogens is advocated [3, 4], meeting the need to restrict antimicrobial selection pressure by promoting subsequent de-escalation guided by culture results. …