A Practical Approach to Clinical Antibiotic Stewardship in the ICU Patient With Severe Infection

Jan Fierens, MD; Pieter O. Depuydt, MD, PhD; Jan J. De Waele, MD, PhD


Semin Respir Crit Care Med. 2019;40(4):435-446. 

In This Article

Abstract and Introduction


Patients with severe infections are often treated with multiple courses of antibiotics in the intensive care unit (ICU), making the ICU a true antibiotic hotspot. The increasing incidence of multidrug resistance worldwide emphasizes the need for continued efforts in developing and implementing antibiotic stewardship programs. Using a pragmatic approach for the bedside clinical team, this review will highlight different key moments for antibiotic decision making throughout the course of the antibiotic treatment in patients with severe infections. We will focus especially on the importance of adequate empirical therapy, source control in infections, assessment of immune status, and two separate antibiotic time-out moments early in the course, as well as the moment of stopping antibiotics. Additionally, the importance of a team-based approach and clinical decision support systems will be highlighted.


Severe community- and hospital-acquired infections are one of the most frequent reasons for admission to an intensive care unit (ICU).[1] Additionally, the critically ill and immunocompromised state of most ICU patients and the inherent risks of organ support systems predispose them to develop infectious complications.[2] This explains the extensive use of antibiotics in the ICU: a multicenter point prevalence study found that 70% of ICU patients were receiving an antibiotic treatment, making the ICU a true antibiotic hotspot.[1] The use of early and adequate empirical antibiotic coverage is pivotal in the treatment of severe infection and sepsis, but antimicrobials are also commonly prescribed in patients without a confirmed infection.[3,4] This increases selection pressure and induces overgrowth of multidrug-resistant (MDR) organisms as demonstrated by the rising incidence of infections caused by extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae, carbapenemase-producing Enterobacteriaceae (CPE), MDR Pseudomonas aeruginosa and Acinetobacter baumannii, methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-intermediate S. aureus (VISA), and vancomycin-resistant enterococci (VRE) in numerous geographic areas.[5–12] It follows that intensivists should be actively participating in the multidisciplinary team responsible for the development, implementation, and promotion of antibiotic stewardship interventions. The main goals of every antibiotic stewardship program (ASP) should be less antibiotic consumption, less antibiotic resistance, and less antibiotic side effects, while bringing about unchanged or improved patient outcomes and an economical benefit. When translating this definition to an ICU setting, ASPs focus on the optimization of agent selection, dose, and duration leading to the best possible clinical outcome, while limiting toxicity and minimizing the development of resistance.[4,13]

This narrative review will give a practical approach to facilitate easy-to-implement ASP interventions at the patient's bedside during day-to-day clinical practice. We will focus particularly on evolving concepts in ASP and how to apply them to severe infection in the ICU.