• Alexis Garduno and Ignacio Martín-Loeches.
• Department of Clinical Medicine, Intensive Care Translational Research, Trinity College Dublin.
• Expert Rev Anti Infect Ther. 2021 Nov 3.

IntroductionThere is an ever-increasing range of antibiotic-resistant pathogens that have led to higher community-acquired infections, and substantial mortality rates in critically ill patients.Areas CoveredWe have critically appraised available evidence through a structured literature review, investigating effective empiric antibiotic administration and appropriateness on outcomes of critically ill patients with an increased risk of developing resistant pathogens. The use of new antibiotics should be determined based on relevant knowledge of their spectrum and properties to provide effective mode of action for critically ill patients.Expert OpinionRestricting severely ill patients access to new broad-spectrum empirical drugs is not the answer. Rather there should be a focus on identifying host response to infection to differentiate between colonization or contamination and true infection, and the sensitivity to antibiotics used in the intensive care unit (ICU).Management relies on adequate antibiotic administration, the ability to monitor response, and facilitate the cessation of antibiotic treatment. The major determinant of patient success in a patient with a severe infection is the 'right' antibiotic or complementary course of treatment. As an overarching criterion, the following 3 appropriate "Ds" should be considered: Dosing, Duration and De-escalation to empirically assess the right antibiotic optimal antimicrobial selection.

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