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

Disclosures

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

In This Article

Developing ASP in the ICU is a Team Effort

Implementing ASP in the ICU environment is challenging, as no single measure alone will be successful. This emphasizes the need for a structured stewardship program. Since the problem is multifaceted, an interdisciplinary team composed of intensivists, ID specialists, clinical pharmacists, clinical microbiologists, and nurses should be partners in this program (Figure 2).[72,113] As indicated by Centers for Disease Control and Prevention (CDC) recommendations, leadership commitment is a core component for successful ASP.[72] The in-depth education and clinical experience of ID specialists makes them natural leaders in the overall hospital ASP. In the ICU on the other hand, integration with ICU leadership and treating intensivists is crucial for a successful ASP. Intensivists have a more in-depth knowledge about critical illness, organ support systems, extracorporeal techniques, and insight into short- and long-term outcomes of ICU patients; also they are at the bedside—often 24/7—when antibiotic decision making is necessary. It should therefore be a core competence for all critical care practitioners. Starting at the trainee level, all intensivists should have a high sense of ownership in all aspects of stewardship.[114] This holds even more true for the patient with severe infections where the use of supportive treatments, such as mechanical ventilation, resuscitation, and when necessary renal replacement therapy and extracorporeal membrane oxygenation, further complicates both the management of the patient and the antibiotic decision making.

Figure 2.

The multidisciplinary team in ASP in the ICU. ASP, antibiotic stewardship program; ID, infectious diseases; PK/PD, pharmacokinetics/pharmacodynamics.

Another critical player is the clinical microbiologist, who provides timely and significant microbiological results, crucial for optimal antibiotic use. While not necessarily directly involved in daily patient care, the microbiologist has a clear understanding of accessibility, performance, and interpretation of several microbial diagnostic tests, especially the newer PCR-based techniques, and how to optimize and facilitate making or refuting the diagnosis of infection.[85,115,116] These new testing modalities can be used to expedite the diagnosis of possible MDR pathogens in clinical samples. The key to successfully use these novel techniques is intertwining the laboratory information to the treating critical care physicians to either initiate or modify antibiotic treatment.[117]

Another integral part of the ASP is the clinical pharmacist. He or she is often active in hospital-wide systems of prior antibiotic approval, restrictive antibiotic formulary, postprescription evaluation, and switch from intravenous to per oral administration. In the ICU department, they provide expertise in pharmacokinetics and pharmacodynamics, essential for dosing consideration in the heterogeneous critically ill population. The impact of a clinical pharmacist in the ASP team was demonstrated by several studies, showing a reduced time to achieve adequate antimicrobial treatment and fewer infectious complications.[118,119] In one study, a temporary absence of a clinical pharmacist was associated with an increased use of restricted antibiotics and longer durations of treatment.[120] Other studies found that mortality in an ICU without a clinical pharmacist's advice was increased in community-acquired infections, hospital-acquired infections, and sepsis.[119,121]

ICU nurses have an underestimated role in the process of ASP, which urgently requires adequate recognition. Realizing the role of communication hub between the treating and referring physicians, pharmacy, laboratory and discharge planners, and nurses could become vital components in ASP teams, particularly in the realm of infection control and prevention.[122] Nurse-driven protocols concerning urinary-catheter-associated infections and catheter-related bloodstream infections have been associated with reduced antibiotic costs, more rapid removal of catheters, and less infectious complications.[123–125] Ample evidence is available, indicating that a multidisciplinary team approach toward ASP can be successful at reducing costs and unnecessary use of antibiotics.[126,127] Many of these studies are limited to the general-ward patient population, warranting more high-quality research in the critical ill population.

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