Timing of antibiotic therapy in the ICU

Abstract

Severe or life threatening infections are common among patients in the intensive care unit (ICU). Most infections in the ICU are bacterial or fungal in origin and require antimicrobial therapy for clinical resolution. Antibiotics are the cornerstone of therapy for infected critically ill patients. However, antibiotics are often not optimally administered resulting in less favorable patient outcomes including greater mortality. The timing of antibiotics in patients with life threatening infections including sepsis and septic shock is now recognized as one of the most important determinants of survival for this population. Individuals who have a delay in the administration of antibiotic therapy for serious infections can have a doubling or more in their mortality. Additionally, the timing of an appropriate antibiotic regimen, one that is active against the offending pathogens based on in vitro susceptibility, also influences survival. Thus not only is early empiric antibiotic administration important but the selection of those agents is crucial as well. The duration of antibiotic infusions, especially for β-lactams, can also influence antibiotic efficacy by increasing antimicrobial drug exposure for the offending pathogen. However, due to mounting antibiotic resistance, aggressive antimicrobial de-escalation based on microbiology results is necessary to counterbalance the pressures of early broad-spectrum antibiotic therapy. In this review, we examine time related variables impacting antibiotic optimization as it relates to the treatment of life threatening infections in the ICU. In addition to highlighting the importance of antibiotic timing in the ICU we hope to provide an approach to antimicrobials that also minimizes the unnecessary use of these agents. Such approaches will increasingly be linked to advances in molecular microbiology testing and artificial intelligence/machine learning. Such advances should help identify patients needing empiric antibiotic therapy at an earlier time point as well as the specific antibiotics required in order to avoid unnecessary administration of broad-spectrum antibiotics.

Keywords: Antibiotics; Outcomes; Pneumonia; Sepsis; Timing.

Fig. 1

Important antibiotic related timelines potentially impacting the outcomes of infected critically ill patients. *Prolonged infusion duration of antimicrobials to increase antimicrobial drug exposure for the offending pathogen

Fig. 2

Bar graph depicting mortality for patients receiving delayed appropriate antibiotic therapy (black bars) and those receiving timely appropriate antibiotic therapy (white bars). See references 5–9 for individual study characteristics

Fig. 3

Solid line depicts increasing risk of mortality for each day that inappropriate antibiotic therapy is continued from the start of treatment. Dash line depicts increasing risk of new antibiotic resistance emergence for each day that antibiotic treatment is continued from the start of treatment