Seminars in respiratory and critical care medicine
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Antimicrobial stewardship encompasses the optimization of agent selection, dose, and duration leading to the best clinical outcome in the treatment or prevention of infection. Ideally, these goals are met while producing the fewest side effects and lowest risk for subsequent resistance. The concept of antimicrobial stewardship can be directly applied to the prescription of empirical antibiotic therapy in the intensive care unit (ICU) because it is well described that inappropriate initial regimens lead to increased mortality. ⋯ Research efforts have concentrated on molecular diagnostic techniques to aid in more rapid organism detection and thus potential for earlier therapy appropriateness and deescalation, although limitations prohibiting widespread implementation of this technology exist. Also of great importance with regard to stewardship efforts is infection prevention. Effective prophylactic strategies reduce the occurrence of nosocomial infections and may therefore improve patient outcomes while obviating the need for otherwise necessary antimicrobial exposure.
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Semin Respir Crit Care Med · Apr 2011
ReviewNew challenges in the diagnosis, management, and prevention of central venous catheter-related infections.
Catheters are the leading source of bloodstream infections in critically ill patients. Because the clinical signs of infection are nonspecific, such infections are overly suspected, which results in unnecessary removal of catheters. A conservative approach might be attempted in mild infections, whereas catheters should always be removed in cases of severe sepsis or septic shock. ⋯ Antiseptic dressings and, to a lesser extent, antimicrobial-coated catheters, might be added to the prevention strategies if the level of infections remains high despite implementation of a prevention program. In the case of CR-BSI in intensive care units (ICUs), the catheter should be removed. In the case of persistence of fever or positive blood cultures after 3 days, inadequate antibiotic therapy, endocarditis, or thrombophlebitis should be ruled out.
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Semin Respir Crit Care Med · Apr 2011
ReviewSelective decontamination of the digestive tract (SDD): is the game worth the candle?
Selective decontamination of the digestive tract (SDD) is an infection prevention strategy in intensive care unit (ICU) patients by topical administration of antibiotics to the mouth and stomach to eradicate potentially pathogenic bacteria and yeast that may cause infections. It also includes a short course of intravenous antibiotics to treat incubating infections at the time of ICU admission. Several randomized, controlled studies, all performed in ICUs with low rates of antibiotic resistance, have shown that SDD prevents ventilator-associated pneumonia and improves survival. ⋯ In areas with low prevalence of MRSA and VRE, SDD should be considered the standard of care in ICUs. In countries where colonization with MRSA and VRE is frequent, resistance may increase, and SDD should be considered experimental therapy. Future research should focus on the effects of SDD compared with SOD on resistance and on SDD-like strategies in areas where MRSA and VRE are endemic.
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Sepsis-induced cardiac dysfunction is a frequent and severe complication of septic shock. The mechanisms responsible for its development are complex and intricate. Echocardiography is the best method to make the diagnosis of cardiac dysfunction. ⋯ The transpulmonary thermodilution monitor and the pulmonary artery catheter can also be used to alert clinicians or to monitor the effects of inotropic therapy. Dobutamine is the first-line therapy. Its administration remains a matter of debate and should be carefully monitored in terms of efficacy and tolerance.
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Semin Respir Crit Care Med · Apr 2011
ReviewValue of the serum procalcitonin level to guide antimicrobial therapy for patients with ventilator-associated pneumonia.
Procalcitonin's contribution to the diagnosis of nosocomial infection, particularly ventilator-associated pneumonia (VAP), is poor: its levels in patients with microbiologically documented VAP the day infection is diagnosed range from normal to extremely high. Moreover, the results of four studies showed that, despite relatively good specificity, this marker had low sensitivity for the diagnosis of VAP. ⋯ Two recent studies showed that a procalcitonin-based strategy (recommending that treating physicians stop antibiotics when the procalcitonin concentration was <0.5 ng/mL, or had decreased by ≥80%) led to less antibiotic consumption by VAP patients, compared with a conventional strategy, with no adverse outcome. Accordingly, for VAP patients, procalcitonin may be used to stop antibiotics as early as day 3 after their initiation, if its concentration is <0.5 ng/mL or has decreased by ≥80%, compared with the first peak concentration.