Marin H Kollef1, Matteo Bassetti2, Bruno Francois3, Jason Burnham4, George Dimopoulos5, Jose Garnacho-Montero6,7, Jeffrey Lipman8,9, Charles-Edouard Luyt10,11, David P Nicolau12, Maarten J Postma13, Antonio Torres14, Tobias Welte15, Richard G Wunderink16. 1. Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 4523 Clayton Avenue, Campus Box 8052, St. Louis, MO, 63110, USA. kollefm@wustl.edu. 2. Infectious Diseases Division, Santa Maria Misericordia University Hospital, Udine, Italy. 3. Service de Réanimation Polyvalente, Inserm CIC-1435, CHU Dupuytren, Limoges, France. 4. Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA. 5. Department of Critical Care, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece. 6. Unidad Clínica de Cuidados Intensivos, Hospital Universitario Virgen Macarena, Seville, Spain. 7. Institute of Biomedicine of Seville, IBiS/CSIC/University of Seville, Seville, Spain. 8. Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Brisbane, QLD, Australia. 9. Burns, Trauma, and Critical Care Research Centre, The University of Queensland, Herston, Brisbane, QLD, Australia. 10. Service de Réanimation, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France. 11. Sorbonne Universités, UPMC Université Paris 06, INSERM, UMRS 1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France. 12. Center for Anti-infective Research and Development and Division of Infectious Diseases, Hartford Hospital, Hartford, CT, USA. 13. Unit of PharmacoTherapy, Epidemiology & Economics, Department of Pharmacy and Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands. 14. Department of Pulmonology, Hospital Clinic of Barcelona, CIBERES, IDIBAPS, University of Barcelona, Barcelona, Spain. 15. Department of Pulmonology, Hannover Medical School, Hannover, Germany. 16. Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
Abstract
PURPOSE: To concisely describe the current standards of care, major recent advances, common beliefs that have been contradicted by recent trials, areas of uncertainty, and clinical studies that need to be performed over the next decade and their expected outcomes with regard to the management of multidrug-resistant (MDR) bacteria, antibiotic use, and antimicrobial stewardship in the intensive care unit (ICU) setting. METHODS: Narrative review based on a systematic analysis of the medical literature, national and international guidelines, and expert opinion. RESULTS: The prevalence of infection of critically ill patients by MDR bacteria is rapidly evolving. Clinical studies aimed at improving understanding of the changing patterns of these infections in ICUs are urgently needed. Ideal antibiotic utilization is another area of uncertainty requiring additional investigations aimed at better understanding of dose optimization, duration of therapy, use of combination treatment, aerosolized antibiotics, and the integration of rapid diagnostics as a guide for treatment. Moreover, there is an imperative need to develop non-antibiotic approaches for the prevention and treatment of MDR infections in the ICU. Finally, clinical research aimed at demonstrating the beneficial impact of antimicrobial stewardship in the ICU setting is essential. CONCLUSIONS: These and other fundamental questions need to be addressed over the next decade in order to better understand how to prevent, diagnose, and treat MDR bacterial infections. Clinical studies described in this research agenda provide a template and set priorities for investigations that should be performed in this field.
PURPOSE: To concisely describe the current standards of care, major recent advances, common beliefs that have been contradicted by recent trials, areas of uncertainty, and clinical studies that need to be performed over the next decade and their expected outcomes with regard to the management of multidrug-resistant (MDR) bacteria, antibiotic use, and antimicrobial stewardship in the intensive care unit (ICU) setting. METHODS: Narrative review based on a systematic analysis of the medical literature, national and international guidelines, and expert opinion. RESULTS: The prevalence of infection of critically illpatients by MDR bacteria is rapidly evolving. Clinical studies aimed at improving understanding of the changing patterns of these infections in ICUs are urgently needed. Ideal antibiotic utilization is another area of uncertainty requiring additional investigations aimed at better understanding of dose optimization, duration of therapy, use of combination treatment, aerosolized antibiotics, and the integration of rapid diagnostics as a guide for treatment. Moreover, there is an imperative need to develop non-antibiotic approaches for the prevention and treatment of MDR infections in the ICU. Finally, clinical research aimed at demonstrating the beneficial impact of antimicrobial stewardship in the ICU setting is essential. CONCLUSIONS: These and other fundamental questions need to be addressed over the next decade in order to better understand how to prevent, diagnose, and treat MDR bacterial infections. Clinical studies described in this research agenda provide a template and set priorities for investigations that should be performed in this field.
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