Sepsis Stewardship: The Puzzle of Antibiotic Therapy in the Context of Individualization of Decision Making

Abstract

The main recent change observed in the field of critical patient infection has been universal awareness of the need to make better use of antimicrobials, especially for the most serious cases, beyond the application of simple and effective formulas or rigid protocols. The increase in resistant microorganisms, the quantitative increase in major surgeries and interventional procedures in the highest risk patients, and the appearance of a significant number of new antibiotics in recent years (some very specifically directed against certain mechanisms of resistance and others with a broader spectrum of applications) have led us to shift our questions from "what to deal with" to "how to treat". There has been controversy about how best to approach antibiotic treatment of complex cases of sepsis. The individualized and adjusted dosage, the moment of its administration, the objective, and the selection of the regimen are pointed out as factors of special relevance in a critically ill patient where the frequency of resistant microorganisms, especially among the Enterobacterales group, and the emergence of multiple and diverse antibiotic treatment alternatives have made the appropriate choice of antibiotic treatment more complex, requiring a constant updating of knowledge and the creation of multidisciplinary teams to confront new infections that are difficult to treat. In this article, we have reviewed the phenomenon of the emergence of resistance to antibacterials and we have tried to share some of the ideas, such as stewardship, sparing carbapenems, and organizational, microbiological, pharmacological, and knowledge tools, that we have considered most useful and effective for individualized decision making that takes into account the current context of multidrug resistance. The greatest challenge, therefore, of decision making in this context lies in determining an effective, optimal, and balanced empirical antibiotic treatment.

Keywords: Antimicrobial Stewardship; Gram negatives; antibiotic treatment; antimicrobial resistance; individualization; new antibiotics; sepsis; septic shock; sparing carbapenems.

Figure 1

The puzzle of antibiotic treatment according to Pea and Viale.

Figure 2

Appropriate/adequate/optimal antibiotic treatment.

Figure 3

Pathophysiological model of Kumar’s sepsis: early antibiotic therapy.

Figure 4

Pathophysiological model of Kumar’s sepsis: delayed antibiotic therapy.

Figure 5

Proposal for antibiotic treatment of nosocomial sepsis that is likely due to resistant Gram-negative microorganisms.