Critical care clinics
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Critical care clinics · Jan 2011
ReviewAntimicrobial pharmacokinetic and pharmacodynamic issues in the critically ill with severe sepsis and septic shock.
Antimicrobial pharmacokinetics (PK) and pharmacodynamics (PD) are important considerations, particularly in critically ill patients with severe sepsis and septic shock. The pathophysiologic changes that occur in these conditions can have a major effect on pharmacokinetic parameters, which in turn could result in failure to achieve pharmacodynamic targets for antimicrobials thus adversely affecting clinical outcome. ⋯ The effect of PK/PD on specific antimicrobial classes is discussed and a rational framework for antimicrobial dosing is provided. Knowledge of PK/PD properties of antimicrobials can be used to personalize dosing regimens not only to maximize antimicrobial activity but also to minimize toxicity and reduce the development of antimicrobial resistance.
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Antibiotic de-escalation is a mechanism whereby the provision of effective initial antibiotic treatment is achieved while avoiding unnecessary antibiotic use that would promote the development of resistance. It is a key element within antimicrobial stewardship programs and treatment paradigms for serious sepsis. ⋯ However, the need for further studies, particularly in terms of realization of full benefits as well as implementation tools, is highlighted. De-escalation ought now to form a part of routine antimicrobial management, though how best to do it and the full breadth and scope of benefits remain to be identified.
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Critical care clinics · Jan 2011
ReviewAntimicrobial therapy for life-threatening infections: speed is life.
For decades, health care workers faced the challenge of how to adequately treat life-threatening infections. To a great extent, the primary focus on improving outcomes has centered on improvement in resuscitation, deployment of antimicrobials of increasing potency, and development of novel adjunctive therapies. However, the current studies conclusively show that early recognition of life threatening infection and rapid initiation of appropriate antimicrobial therapy is the critical element in reducing mortality. If "Time is tissue" when it comes to thrombolytic therapy for acute myocardial infarction and thrombotic stroke, then an appropriate rule for life-threatening infections, particularly septic shock, is "Speed is life."