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Antibiotic stewardship in the intensive care unit: Challenges and opportunities

  • Kathleen Chiotos (a1) (a2) (a3), Pranita D. Tamma (a4) and Jeffrey S. Gerber (a2) (a3)


Infections due to antibiotic-resistant organisms are increasing in prevalence and represent a major public health threat. Antibiotic overuse is a major driver of this epidemic, and antibiotic stewardship an important means of limiting antibiotic resistance. The intensive care unit (ICU) setting presents an intersection of opportunities and challenges for effective antibiotic stewardship, but limited data inform optimal stewardship interventions in this setting. In this review, we present unique considerations for stewardship interventions the ICU setting and summarize available data evaluating the impact of prospective audit and feedback, diagnostic test stewardship, rapid molecular diagnostic tests, and procalcitonin-guided algorithms for antibiotic discontinuation. The existing knowledge gaps ripe for future research are emphasized.


Corresponding author

Author for correspondence: Jeffrey S. Gerber, E-mail:


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1. Antibiotic resistance threats in the United States. Centers for Disease Control and Prevention website. Published 2013. Accessed August 13, 2018.
2. Shields, RK, Potoski, BA, Haidar, G, et al. Clinical outcomes, drug toxicity, and emergence of ceftazidime-avibactam resistance among patients treated for carbapenem-resistant Enterobacteriaceae infections. Clin Infect Dis 2016;63:16151618.
3. Kumar, A, Roberts, D, Wood, KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 2006;34:15891596.
4. Approved: new antimicrobial stewardship standard. The Joint Commission website. Published 2016. Accessed August 13, 2018.
5. Shorr, AF, Zilberberg, MD, Micek, ST, Kollef, MH. Predictors of hospital mortality among septic ICU patients with Acinetobacter spp bacteremia: a cohort study. BMC Infect Dis 2014;14:572578.
6. Weiner, LM, Webb, AK, Limbago, B, et al. Antimicrobial-resistant pathogens associated with healthcare-associated infections: summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2011–2014. Infect Control Hosp Epidemiol 2016;37:12881301.
7. Vincent, JL, Rello, J, Marshall, J, et al. International study of the prevalence and outcomes of infection in intensive care units. JAMA 2009;302:23232329.
8. Barlam, TF, Cosgrove, SE, Abbo, LM, et al. Implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis 2016;62:e51e77.
9. Cusini, A, Rampini, SK, Bansal, V, et al. Different patterns of inappropriate antimicrobial use in surgical and medical units at a tertiary care hospital in Switzerland: a prevalence survey. PloS One 2010;5:e14011.
10. Thomas, Z, Bandali, F, Sankaranarayanan, J, Reardon, T, Olsen, KM. A multicenter evaluation of prolonged empiric antibiotic therapy in adult ICUs in the United States. Crit Care Med 2015;43:25272534.
11. Rhodes, A, Evans, LE, Alhazzani, W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016. Intensive Care Med 2017;43:304377.
12. Seymour, CW, Gesten, F, Prescott, HC, et al. Time to treatment and mortality during mandated emergency care for sepsis. N Engl J Med 2017;376:22352244.
13. Klein Klouwenberg, PM, Cremer, OL, van Vught, LA, et al. Likelihood of infection in patients with presumed sepsis at the time of intensive care unit admission: a cohort study. Crit Care 2015;19:319.
14. Elligsen, M, Walker, SA, Pinto, R, et al. Audit and feedback to reduce broad-spectrum antibiotic use among intensive care unit patients: a controlled interrupted time series analysis. Infect Control Hosp Epidemiol 2012;33:354361.
15. Taggart, LR, Leung, E, Muller, MP, Matukas, LM, Daneman, N. Differential outcome of an antimicrobial stewardship audit and feedback program in two intensive care units: a controlled interrupted time series study. BMC Infect Dis 2015;15:480.
16. Rimawi, RH, Mazer, MA, Siraj, DS, Gooch, M, Cook, PP. Impact of regular collaboration between infectious diseases and critical care practitioners on antimicrobial utilization and patient outcome. Crit Care Med 2013;41:20992107.
17. Lindsay, PJ, Rohailla, S, Taggart, LR, et al. Antimicrobial stewardship and intensive care unit (ICU) mortality: a systematic review. Clin Infect Dis 2019;68:748756.
18. Steinberg, M, Dresser, LD, Daneman, N, et al. A national survey of critical care physicians’ knowledge, attitudes, and perceptions of antimicrobial stewardship programs. J Intensive Care Med 2016;31:6165.
19. Schweizer, ML, Braun, BI, Milstone, AM. Research methods in healthcare epidemiology and antimicrobial stewardship quasi-experimental designs. Infect Control Hosp Epidemiol 2016;37:11351140.
20. Gerber, JS, Prasad, PA, Fiks, AG, Localio, AR, Bell, LM, Keren, R, Zaoutis, TE. Durability of benefits of an outpatient antimicrobial stewardship intervention after discontinuation of audit and feedback. JAMA 2014;312:25692570.
21. Wilde, AM, Nailor, MD, Nicolau, DP, Kuti, JL. Inappropriate antibiotic use due to decreased compliance with a ventilator-associated pneumonia computerized clinical pathway: implications for continuing education and prospective feedback. Pharmacotherapy 2012;32:755763.
22. Epstein, L, Edwards, JR, Halpin, AL, et al. Evaluation of a novel intervention to reduce unnecessary urine cultures in intensive care units at a tertiary care hospital in Maryland, 2011–2014. Infect Control Hosp Epidemiol 2016;37:606609.
23. Trautner, BW, Grigoryan, L, Petersen, NJ, et al. Effectiveness of an antimicrobial stewardship approach for urinary catheter-associated asymptomatic bacteriuria. JAMA Intern Med 2015;175:11201127.
24. Banerjee, R, Teng, CB, Cunningham, SA, et al. Randomized trial of rapid multiplex polymerase chain reaction-based blood culture identification and susceptibility testing. Clin Infect Dis 2015;61:10711080.
25. Perez, KK, Olsen, RJ, Musick, WL, et al. Integrating rapid diagnostics and antimicrobial stewardship improves outcomes in patients with antibiotic-resistant gram-negative bacteremia. J Infection 2014;69:216225.
26. Huang, AM, Newton, D, Kunapuli, A, et al. Impact of rapid organism identification via matrix-assisted laser desorption/ionization time-of-flight combined with antimicrobial stewardship team intervention in adult patients with bacteremia and candidemia. Clin Infect Dis 2013;57:12371245.
27. Forrest, GN, Roghmann, MC, Toombs, LS, et al. Peptide nucleic acid fluorescent in situ hybridization for hospital-acquired enterococcal bacteremia: delivering earlier effective antimicrobial therapy. Antimicrob Agents Chemother 2008;52:35583563.
28. MacVane, SH, Hurst, JM, Boger, MS, Gnann, JW Jr. Impact of a rapid multiplex polymerase chain reaction blood culture identification technology on outcomes in patients with vancomycin-resistant Enterococcal bacteremia. Infect Dis 2016;48:732737.
29. Timbrook, TT, Morton, JB, McConeghy, KW, Caffrey, AR, Mylonakis, E, LaPlante, KL. The effect of molecular rapid diagnostic testing on clinical outcomes in bloodstream infections: a systematic review and meta-analysis. Clin Infect Dis 2017;64:1523.
30. Coopersmith, CM, De Backer, D, Deutschman, CS, et al. Surviving sepsis campaign: research priorities for sepsis and septic shock. Crit Care Med 2018;46:13341356.
31. Kollef, MH, Bassetti, M, Francois, B, et al. The intensive care medicine research agenda on multidrug-resistant bacteria, antibiotics, and stewardship. Intensive Care Med 2017;43:11871197.
32. Layios, N, Lambermont, B, Canivet, JL, et al. Procalcitonin usefulness for the initiation of antibiotic treatment in intensive care unit patients. Crit Care Med 2012;40:23042309.
33. Bouadma, L, Luyt, CE, Tubach, F, et al. Use of procalcitonin to reduce patients’ exposure to antibiotics in intensive care units (PRORATA trial): a multicentre randomised controlled trial. Lancet 2010;375:463474.
34. Shehabi, Y, Sterba, M, Garrett, PM, et al. Procalcitonin algorithm in critically ill adults with undifferentiated infection or suspected sepsis. A randomized controlled trial. Am J Resp Crit Care Med 2014;190:11021110.
35. de Jong, E, van Oers, JA, Beishuizen, A, et al. Efficacy and safety of procalcitonin guidance in reducing the duration of antibiotic treatment in critically ill patients: a randomised, controlled, open-label trial. Lancet Infect Dis 2016;16:819827.
36. Wirz, Y, Meier, MA, Bouadma, L, et al. Effect of procalcitonin-guided antibiotic treatment on clinical outcomes in intensive care unit patients with infection and sepsis patients: a patient-level meta-analysis of randomized trials. Crit Care 2018;22:191.
37. Jensen, JU, Hein, L, Lundgren, B, et al. Procalcitonin-guided interventions against infections to increase early appropriate antibiotics and improve survival in the intensive care unit: a randomized trial. Crit Care Med 2011;39:20482058.
38. Parente, DM, Cunha, CB, Mylonakis, E, Timbrook, TT. The clinical utility of methicillin-resistant Staphylococcus aureus (MRSA) nasal screening to rule out MRSA pneumonia: a diagnostic meta-analysis with antimicrobial stewardship implications. Clin Infect Dis 2018;67:17.
39. Willson, DF, Kirby, A, Kicker, JS. Respiratory secretion analyses in the evaluation of ventilator-associated pneumonia: a survey of current practice in pediatric critical care. Pediatr Crit Care Med 2014;15:715719.
40. Evans, SR, Rubin, D, Follmann, D, et al. Desirability of outcome ranking (DOOR) and response adjusted for duration of antibiotic risk (RADAR). Clin Infect Dis 2015;61:800806.
41. Szymczak, JE,Newland, J. The social determinants of antimicrobial prescribing: Implications for antimicrobial stewardship. In: Barlam, TNM, Tamma, P, Trivedi, K (editors). Practical Implementation of an Antibiotic Stewardship Program. Cambridge, UK: Cambridge University Press; 2018.
42. van Santen, KL, Edwards, JR, Webb, AK, et al. The standardized antimicrobial administration ratio: a new metric for measuring and comparing antibiotic use. Clin Infect Dis 2018;67:179185.
43. Kallen, MC, Roos-Blom, MJ, Dongelmans, DA, et al. Development of actionable quality indicators and an action implementation toolbox for appropriate antibiotic use at intensive care units: a modified-RAND Delphi study. PloS One 2018;13:e0207991.
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Infection Control & Hospital Epidemiology
  • ISSN: 0899-823X
  • EISSN: 1559-6834
  • URL: /core/journals/infection-control-and-hospital-epidemiology
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