Controversies in the antibiotic management of critically ill patients.
Preventing infection, managing antibiotics, and controlling antibiotic resistance are integral to the daily practice of any physician caring for critically ill patients. Many controversies remain in this area, but improving our ability to manage anti-infective drugs is likely to be a determinant factor on the outcome of critically ill patients. Several measures to prevent nosocomial infections are available, including selective digestive decontamination (SDD) and antibiotic-coated catheters, but a careful assessment of the effect of these strategies upon resistance is needed before considering their extensive use in the ICU. Antibiotic therapy of severely infected patients can be considered as a two-step contract, the first part of which consists in providing individual patients with the best antibiotic strategy. This raises important, although often unsolved, questions regarding the dose, the interest of combining two antibiotics, and the length of therapy. The second part of the contract concerns not only individual patients but the community. Reassessment of the initial therapy is mandatory to avoid prolonged and unnecessary usage of broad spectrum and costly antibiotics, which increase resistance pressure. In many cases, antibiotics can be either stopped or changed after 2 or 3 days.
Carlet
J M
JM
Fondation-Hopital Saint-Joseph, Paris, France.