Seminars in respiratory and critical care medicine
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Semin Respir Crit Care Med · Aug 2019
ReviewA Practical Approach to Clinical Antibiotic Stewardship in the ICU Patient with Severe Infection.
Patients with severe infections are often treated with multiple courses of antibiotics in the intensive care unit (ICU), making the ICU a true antibiotic hotspot. The increasing incidence of multidrug resistance worldwide emphasizes the need for continued efforts in developing and implementing antibiotic stewardship programs. ⋯ We will focus especially on the importance of adequate empirical therapy, source control in infections, assessment of immune status, and two separate antibiotic time-out moments early in the course, as well as the moment of stopping antibiotics. Additionally, the importance of a team-based approach and clinical decision support systems will be highlighted.
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Semin Respir Crit Care Med · Aug 2019
ReviewManagement and Prevention of Central Venous Catheter-Related Infections in the ICU.
Central venous catheter-related bloodstream infections (CR-BSI) are a frequent event in the intensive care unit (ICU) setting. In contrast to other nosocomial infections, most risk factors for CR-BSI are linked to the device and can be prevented efficiently. Rates of CR-BSI higher than 1 per 1,000 catheter days are no longer acceptable. ⋯ While awaiting culture results, an empiric antimicrobial treatment of CR-BSI should target gram-positive microorganism (i.e., Staphylococcus aureus) and gram-negative coverage should be based on clinical variables, patients' risk factors, and previous colonization status. While a short course of antimicrobials (7 days) is sufficient for noncomplicated CR-BSI, a longer course of 14 days should be preferred for uncomplicated S. aureus and Candida CR-BSI. In case of persisting fever or positive blood culture after 3 days despite adequate antimicrobial therapy and catheter removal, catheter-related complications (e.g., endocarditis, thrombophlebitis, septic metastasis) should be ruled out.
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With the overall improvement in survival of cancer patients and the widespread use of novel immunotherapy drugs for malignant as well as nonmalignant diseases, the prevalence of immunosuppression is rising in the population. Immunocompromised patients are particularly exposed to pulmonary infections which remain a leading cause for acute hypoxic respiratory failure and intensive care unit admission. ⋯ Adequate and timely prevention, diagnosis, and management of bacterial pneumonias require knowledge about the complex interplay between host factors (type and severity of immunosuppression) and bacterial pathogenesis, to improve the outcome. We provide an overview of bacterial pneumonias in immunocompromised patients including their epidemiology, risk factors with respect to the pattern of immunosuppression, microbiological characteristics, diagnostic approach, management, and prevention.