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. 1990;16(Suppl 3):S243–S247. doi: 10.1007/BF01709709

Treatment of sepsis in an intensive care unit

C C Smith 1,2
PMCID: PMC7095458  PMID: 2289999

Abstract

The management of severe bacterial sepsis is an integral part of intensive care medicine. Early and appropriate treatment with antimicrobials positively affects mortality and significantly reduces the time spent in both intensive care and the hospital. Drug choice is usually made on a “best guess” basis and instituted prior to receipt of appropriate blood, sputum, urine or drainage culture results. Bactericidal drugs should be given in combination, delivered by intravenous bolus and directed towards broad cover of all likely pathogens. Aminoglycoside/ureidopenicillin combinations are synergistic and widely used — often combined with metronidazole. Aminoglycoside toxicity can be reduced by giving the drug once daily (OD) rather than by traditional multiple daily dosing (MDD) and by measuring peak and trough serum levels. Efficacy is increased by attention to the peak serum level/MIC ratio which determines the response to treatment. Several newer agents have been more recently introduced. These drugs include ceftazidime, imipenem/cilastatin, the quinolones and clavulanic acid/semisynthetic penicillin combinations. Other newer drugs currently under evaluation include aztreonam, teicoplanin, the penems and carbapenems.

Key words: Severe infection, ITU setting, “best guess” choice, Bactericidal antimicrobials, Combinations vs. monotherapy, Prevention of nosocomial infection

References

  • 1.Myers BR, Sherman E, Mendelson MH, Valesquez G, Srulevitch-Chin E, Hubbard M, Hirschmann SZ. Bloodstream infections in the elderly. Am J Med. 1989;86:379. doi: 10.1016/0002-9343(89)90333-1. [DOI] [PubMed] [Google Scholar]
  • 2.Kreger BE, Craven DE, McCabe WR. Gram-negative bacteraemia. The evaluation of clinical features and treatment in 612 patients. Am J Med. 1980;68:344. doi: 10.1016/0002-9343(80)90102-3. [DOI] [PubMed] [Google Scholar]
  • 3.Bone RC, Fisher CJ, Clemmer IP, Stonann GJ, Metz CA, Balh RA. Sepsis syndrome: a valid clinical entity. Crit Care Med. 1989;12:389. [PubMed] [Google Scholar]
  • 4.L'a Force RM. Hospital acquired Gram-negative rod pneumonias: an overview. Am J Med. 1981;70:664. doi: 10.1016/0002-9343(81)90593-3. [DOI] [PubMed] [Google Scholar]
  • 5.Daschner FD, Frey P, Wolff G, Bannann PC, Suter P. Nosocomial infections in intensive care wards: a multicentre prospective study. Intensive Care Med. 1982;8:5. doi: 10.1007/BF01686847. [DOI] [PubMed] [Google Scholar]
  • 6.Van Uffelen R, Rommes JH, Fidler V, van Saene HK. Preventing lower airway colonisation and infection in mechanically ventilated patients. Crit Care Med. 1987;15:99. doi: 10.1097/00003246-198702000-00003. [DOI] [PubMed] [Google Scholar]
  • 7.Smith CC. Initial antibacterial therapy in patients with septicaemia. Res Clin Forums. 1986;8:7–15. [Google Scholar]
  • 8.Allan SG, Glover SC, Smith CC, Reid TMS. An open study of ceftazidime in the treatment of serious bacterial infections. J Antimicrob Chemother. 1983;12:219–227. doi: 10.1093/jac/12.3.219. [DOI] [PubMed] [Google Scholar]
  • 9.Imipenem/Cilastatin; monotherapy of hospital infections (1987) Scand J Infect Dis [Suppl 52]:5–78 [PubMed]
  • 10.Smith G. Use of aztreonam in serious Gram-negative infections. J Antimicrob Chemother. 1988;21:233–241. doi: 10.1093/jac/21.2.233. [DOI] [PubMed] [Google Scholar]
  • 11.Hawkey PM. Where are we now with Ciprofloxacin? Leading article. J Antimicrob Chemother. 1989;24:477–479. doi: 10.1093/jac/24.4.477. [DOI] [PubMed] [Google Scholar]
  • 12.Brogden RN, Heel RC. Aztreonam: a review of its antibacterial activity, pharmacokinetic properties and therapeutic use. Drugs. 1986;31:96–130. doi: 10.2165/00003495-198631020-00002. [DOI] [PubMed] [Google Scholar]
  • 13.Williams AH, Grüneberg RN. Teicophanin revisited: leading article. J Antimicrob Chemother. 1988;22:392–399. doi: 10.1093/jac/22.4.397. [DOI] [PubMed] [Google Scholar]
  • 14.Bryan CS, Reynolds KL, Brenner ER. Analysis of 1186 episodes of Gram-negative bacteraemia in a non-university hospital: effects of antimicrobial therapy. Rev Infect Dis. 1983;5:629–638. doi: 10.1093/clinids/5.4.629. [DOI] [PubMed] [Google Scholar]
  • 15.Hata JS. Infections in the critical care unit. Curr Opinion Infect Dis. 1989;25:659–662. [Google Scholar]
  • 16.Elliott TSJ. Intravascular device infections. J Med Microbiol. 1988;27:161–167. doi: 10.1099/00222615-27-3-161. [DOI] [PubMed] [Google Scholar]
  • 17.Martin MA, Pfaller WA, Wenzel RP. Coagulase-negative staphylococcal bacteraemia: mortality and hospital stay. Ann Intern Med. 1989;110:9–16. doi: 10.7326/0003-4819-110-1-9. [DOI] [PubMed] [Google Scholar]
  • 18.Moor RD, Smith CR, Wipshy JJ, Mellitis ED, Wietman PS. Risk factors for nephrotoxicity in patients treated with aminoglycosides. Ann Intern Med. 1984;100:352–357. doi: 10.7326/0003-4819-100-3-352. [DOI] [PubMed] [Google Scholar]
  • 19.Keller F, Borner K, Schwartz A, Offerman G, Node H. Therapeutic aminoglycoside monitoring in renal failure patients. Ther Drug Monit. 1987;9:148–153. doi: 10.1097/00007691-198706000-00004. [DOI] [PubMed] [Google Scholar]
  • 20.Editorial (1986) Aminoglycoside toxicity. Lancet II:670–671 [PubMed]
  • 21.Chastre J, Fagon JY, Soler P, Bornet M, Domart Y, Tromiket JL, Gibert C, Hance AJ. Diagnosis of nosocomial bacterial pneumonia in intubated patients undergoing ventilation: comparison of usefulness of bronchoalveolar lavage and the protected specimen brush. Am J Med. 1988;85:499–506. doi: 10.1016/s0002-9343(88)80085-8. [DOI] [PubMed] [Google Scholar]
  • 22.Craven DE, Kunches LM, Lichtenberg DA, Kollisch NR, Barry MA, Heeren TC, McCake WR. Nosocomial infection and fatality in medical and surgical intensive care patients. Arch Intern Med. 1988;148:1161–1168. [PubMed] [Google Scholar]
  • 23.Stoutenbeek CP, van Saene HKF, Miranda DR, Zandstra DF. The effect of selective decontamination of the digestive track on colonisation and infection rate in multiple trauma patients. Intensive Care Med. 1984;10:185–192. doi: 10.1007/BF00259435. [DOI] [PubMed] [Google Scholar]
  • 24.Ledingham IMcA, Alcock SR, Eastaway AT, McDonald JC, McKay IC, Ramsay G. Triple regimen of selective decontamination of digestive tract, systemic cefotaxime and microbiological surveillance for prevention of acquired infection in intensive care. Lancet. 1988;I:785–790. doi: 10.1016/s0140-6736(88)91656-x. [DOI] [PubMed] [Google Scholar]
  • 25.Moore RD, Smith CR, Wietman PS. The association of aminoglycoside plasma levels with mortality in patients with gramnegative bacteraemia. J Infect Dis. 1984;149:443–448. doi: 10.1093/infdis/149.3.443. [DOI] [PubMed] [Google Scholar]
  • 26.John JF. What price success? The continuing saga of the toxic/therapeutic ratio with aminoglycoside antibiotics. J Infect Dis. 1988;158:1–6. doi: 10.1093/infdis/158.1.1. [DOI] [PubMed] [Google Scholar]
  • 27.Drusano GL. Role of pharmacokinetics in the outcome of infection. Antimicrob Agents Chemother. 1988;32:289–297. doi: 10.1128/aac.32.3.289. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28.Moore RD, Wietman PS, Smitz CR. Clinical response to aminoglycoside therapy: importance of ratio of peak concentration to MIC. J Infect Dis. 1987;155:93–99. doi: 10.1093/infdis/155.1.93. [DOI] [PubMed] [Google Scholar]
  • 29.Flint LM, Gott J, Short L, Richardson JD, Polk HC. Serum level monitoring of aminoglycoside antibiotics. Arch Surg. 1985;120:99–102. doi: 10.1001/archsurg.1985.01390250087014. [DOI] [PubMed] [Google Scholar]
  • 30.Mattie H, Craig WA, Pechere JC. Determinants of efficacy and toxicity of aminoglycosides. J Antimicrob Chemother. 1989;24:281–293. doi: 10.1093/jac/24.3.281. [DOI] [PubMed] [Google Scholar]
  • 31.Sturm AW. Netilmicin in the treatment of gram-negative bacteraemia — Single dose vs multiple daily dosing. J Infect Dis. 1989;159:931. doi: 10.1093/infdis/159.5.931. [DOI] [PubMed] [Google Scholar]
  • 32.Smith CC. Clinically important adverse drug interactions, vol 3. Amsterdam: Elsevier; 1985. The penicillins and cephalosporins; pp. 111–153. [Google Scholar]
  • 33.Richards DM, Brodgen RN. Ceftazidime. A review of its antibacterial activity, pharmacokinetic properties and therapeutic use. Drugs. 1985;29:105–161. doi: 10.2165/00003495-198529020-00002. [DOI] [PubMed] [Google Scholar]
  • 34.Graham J. Imipenem in the treatment of severe bacterial infections in serious sick patients. J Antimicrob Chemother. 1986;18(Suppl E):131–140. doi: 10.1093/jac/18.supplement_e.131. [DOI] [PubMed] [Google Scholar]
  • 35.Robinson GN. β-lactamase induction and resistance to β-lactam antibiotics. J Antimicrob Chemother. 1989;23:12. doi: 10.1093/jac/23.1.1. [DOI] [PubMed] [Google Scholar]
  • 36.Clavulanate/β-lactam antibiotics: Further experience (1989). J Antimicrob Chemother [Suppl B] 24:1–221
  • 37.Warnock DW. Jtraconazole and fluconazole: new drugs for deep fungal infection. J Antimicrob Chemother. 1989;24:275–277. doi: 10.1093/jac/24.3.275. [DOI] [PubMed] [Google Scholar]
  • 38.Van Wout JW, Mattie H, van Furth R. A prospective study of the efficacy of fluconazole against deep seated fungal infections. J Antimicrob Chemother. 1988;21:665–672. doi: 10.1093/jac/21.5.665. [DOI] [PubMed] [Google Scholar]
  • 39.Cytomegalovirus: the disease and its management (1989). J Antimicrob Chemother [Suppl E] 23:1–20 [PubMed]
  • 40.Cefmetazole: a clinical appraisal (1989). J Antimicrob Chemother [Suppl A] 23:1–131 [PubMed]
  • 41.Meropenem: a new carbapenem (1989). J Antimicrob Chemother [Suppl A] 24:1–311
  • 42.Zaske DE, Cipolle RJ, Rotschager JC. Gentamicin pharmacokinetics in 1640 patients: method for control of serum concentrations. Antimicrob Agents Chemother. 1982;30:78. doi: 10.1128/aac.21.3.407. [DOI] [PMC free article] [PubMed] [Google Scholar]

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