How should we dose antibiotics for pneumonia in the ICU?

Abstract

PURPOSE OF REVIEW: Pneumonia continues to be a common reason for, or complication of, ICU admission. Associated morbidity and mortality remain high, with an increasing incidence of multidrug-resistant organisms. Appropriate antibiotic therapy, both in terms of spectrum of cover and dose, remains the cornerstone of effective management. RECENT FINDINGS: Critically ill patients will frequently manifest significantly altered end-organ function, as compared with an ambulatory or ward-based setting. Such changes can have profound effects on antibiotic drug handling, promoting subtherapeutic concentrations, treatment failure or the selection of resistant organisms. Standard antibiotic regimens typically fail to consider such issues, with recent literature highlighting the need for improved dosing to achieve sufficient intrapulmonary concentrations, particularly in the setting of augmented elimination. Although recent clinical trials utilizing strategies that optimize drug exposure (either through the use of agents with improved penetration, or continuous infusions) demonstrate superior surrogate outcomes, a mortality benefit is still uncertain. SUMMARY: Antibiotic dosing strategies that are adapted to a critical care environment are urgently needed, both to improve clinical outcomes and ensure therapeutic longevity. Similarly, study protocols investigating emerging antibiotics must also be designed accordingly, to prevent potential setbacks in drug availability. © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins.