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Fighting Resistance in the ICU

(from the March 2019 ACP Hospitalist)

Ongoing growth in antibiotic resistance has highlighted both the importance and the challenge of frontline stewardship.

By Mollie Frost

While medicine as a whole is advancing, physicians have lost some ground against bacteria, particularly in the ICU.

“For a lot of patients, we've entered the preantibiotic era, where we're essentially practicing 19th-century medicine and having to do surgery and debride because there are no antibiotics. . . . We see those cases now, and that's the reality of 2019,” said Michael Stevens, MD, MPH, FACP, director of the antimicrobial stewardship program at VCU Health in Richmond, VA.

Growth in antibiotic resistance has highlighted both the importance and the challenge of frontline stewardship in the ICU. Early appropriate antibiotics have been proven to save lives, but overuse carries increasingly serious consequences.

Even a dose or two of very broad-spectrum antibiotics cause dramatic changes in the human microbiome, which can have a host of downstream effects, noted John A. Sellick, DO, MS, FACP, professor of medicine in the division of infectious diseases at the University at Buffalo in New York. “We're at the point now where, even in the first culture out, we're seeing resistant organisms,” he said. “In the past, we would rarely see that in those early cultures.”

To help hospitalists bring their best to this battle, antimicrobial stewardship experts offered tips on antibiotic selection, de-escalation, and stewardship interventions.

Starting broadly

For better or for worse, there tends to be a “better safe than sorry” mentality with antibiotics in the ICU, said Daniel J. Morgan, MD, MS, chief hospital epidemiologist at the Veterans Affairs Maryland Healthcare System in Baltimore. “It's often unclear what's making these patients sick, so the decision is often made to give them antibiotics—even if it seems unlikely that an infection is clearly part of what's making them sick,” he said.

That can be the correct choice, experts said. “If a patient's really sick and you're not sure what's going on, it is always OK to start broad. That's not usually the time to be judicious,” said Sarah Doernberg, MD, MAS, associate professor of clinical medicine and medical director of adult antimicrobial stewardship at the University of California, San Francisco (UCSF).

How broad to go is less clear, and it depends on the patient and setting. “It's important for everybody to know what organisms are in their community and what their empiric, up-front antibiotics should be,” said Gail Scully, MD, an assistant professor at the University of Massachusetts Medical School in Worcester, MA.

Once broad-spectrum therapy is started, it's time to start thinking about narrowing it down to target the right pathogens. Since ICU patients are often intubated and unable to speak, the electronic health record (EHR) and family members can provide useful information on where the patient has recently been and other potential risk factors for drug-resistant bacteria, Dr. Doernberg said.

However, the EHR doesn't show the whole picture, especially if the patient was in a different hospital unconnected to the system, and documentation about other health care exposure risks can be poor, she noted. “So I think taking a good history with the family, if you're able to get them, can be very helpful” to get information on patients and their first symptoms, said Dr. Doernberg.

Read the full article in ACP Hospitalist.

ACP Hospitalist provides news and information about hospital medicine, covering the latest trends and issues in the field.

Back to the April 2019 issue of ACP IMpact