Evidence for immediate adequate parenteral antibiotics

Abstract

Over half of all patients admitted to intensive care units (ICUs) receive one or more antimicrobial agents, and most of these are for the treatment of community-acquired and/or nosocomial infections [1]. In a surveillance study, antibiotic use and related costs were prospectively analysed in a general ICU ward over a 1-year period. Antibiotics were prescribed in 61% of admissions. Categorised by indication, 59%of all antibiotic prescriptions were for bacteriologically proven infections, 28% for non-bacteriologically proven infections and 13% for prophylaxis [2]. In the absence of a precise diagnosis of infection, the modern practice of critical care medicine dictates that empirical antibiotic therapy be given [3]. Providing early antimicrobial therapy, which is effective against the microorganisms responsible for infections in hospitalised patients, is recognised as a crucial step for the treatment of acquired infections, along with drainage of infected fluid collections and the debridement or removal of infected tissues or prostheses [4]. Promptly initiating (at the first sign of an infection) appropriate empirical antimicrobial therapy in patients with life-threatening illnesses seems to be the most effective treatment approach [5]. Traditionally empiric treatment has been to start with an inexpensive narrow-spectrum agent, broadening therapy only if a multi-resistant pathogen is identified or the patient deteriorates. This approach may have served to select continuously from a heterogeneous bacterial population, strains that are first-step resistant mutants and, thus, start us on the slippery slope to resistance crises [3].