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Intensive Care Med. 2019 Feb;45(2):172-189. doi: 10.1007/s00134-019-05520-5. Epub 2019 Jan 18.

Rationalizing antimicrobial therapy in the ICU: a narrative review.

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Medical and Infectious Diseases ICU, APHP, Bichat-Claude Bernard Hospital, 46 Rue Henri-Huchard, 75877, Paris Cedex 18, France.
INSERM, IAME, UMR 1137, Paris-Diderot Sorbonne-Paris Cité University, Paris, France.
Infectious Diseases Division, Department of Medicine, University of Udine and Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy.
Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands.
Scool of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium.
Department of Internal Medicine, Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, USA.
Surgical Critical Care Unit, Department of Anesthesiology, Critical Care and Perioperative Medicine, CHU Lille, Lille, France.
Critical Care Research, Washington University School of Medicine and Respiratory Care Services, Barnes-Jewish Hospital, St. Louis, MO, USA.
Department of Medicine, Royal Inland Hospital, Kamloops, Canada.
Intensive Care Medicine Department, Centro Hospitalar São João and Faculty of Medicine, University of Porto, Porto, Portugal.
Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, Hospital Universitario Virgen Macarena, Departament of Medicine, University of Sevilla, Biomedicine Institute of Seville (IBiS), Seville, Spain.
INSERM, IAME, UMR 1137, Paris-Diderot Sorbonne-Paris Cité University, Paris, France.
Bacteriology Laboratory, Bichat-Claude Bernard Hospital, APHP, Paris, France.
Department of Critical Care and Graduate Program in Translational Medicine, D'Or Institute for Research and Education, IDOR, Rio De Janeiro, Brazil.
Department of Intensive Care, Erasme Hospital, Brussels, Belgium.
Department of Anesthesiology and Critical Care, Beaujon Hospital, AP-HP, Clichy, France.
INSERM, CRI, UMR 1149, Paris-Diderot Sorbonne-Paris Cité University, Paris, France.
Medical ICU, La Source Hospital, CHR Orléans, Orléans, France.


The massive consumption of antibiotics in the ICU is responsible for substantial ecological side effects that promote the dissemination of multidrug-resistant bacteria (MDRB) in this environment. Strikingly, up to half of ICU patients receiving empirical antibiotic therapy have no definitively confirmed infection, while de-escalation and shortened treatment duration are insufficiently considered in those with documented sepsis, highlighting the potential benefit of implementing antibiotic stewardship programs (ASP) and other quality improvement initiatives. The objective of this narrative review is to summarize the available evidence, emerging options, and unsolved controversies for the optimization of antibiotic therapy in the ICU. Published data notably support the need for better identification of patients at risk of MDRB infection, more accurate diagnostic tools enabling a rule-in/rule-out approach for bacterial sepsis, an individualized reasoning for the selection of single-drug or combination empirical regimen, the use of adequate dosing and administration schemes to ensure the attainment of pharmacokinetics/pharmacodynamics targets, concomitant source control when appropriate, and a systematic reappraisal of initial therapy in an attempt to minimize collateral damage on commensal ecosystems through de-escalation and treatment-shortening whenever conceivable. This narrative review also aims at compiling arguments for the elaboration of actionable ASP in the ICU, including improved patient outcomes and a reduction in antibiotic-related selection pressure that may help to control the dissemination of MDRB in this healthcare setting.


Antibiotic stewardship; Antimicrobial resistance; Carbapenem; Critical illness; Empirical therapy; Outcome; Sepsis

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