Optimizing Antimicrobials in Sepsis
Anti-infective therapy is the cornerstone of treatment for critically ill patients with sepsis and septic shock. The choice of initial empiric antimicrobial therapy is crucial in determining positve otucomes. The optimal selection of antibiotics depends on the local resistance epidemiology as well as individual risk factors for resistance, including recent antibiotic use, hospitalization, and previous colonization or infection with resistant strains. The speed with which appropriate antimicrobials are initiated is now well recognized as a crucial element in providing effective care of patients with all life threatening infections including septic shock. In addition, maximization of cidality through pharmacokinetic optimization and combination therapy can be useful.
Anidulafungin, a cidal antifungal echinocandin, demostrated superiority over fluconazole, a static triazole, in invasive candida infections. Higher cidal activity of antibiotic regimens are associated with better clinical cure rates in bacterial endocarditis, osteomyelitis and in neutropenic gram-negative bacteremia.
The cidal lipopeptide, daptomycin, tends to be superior to vancomycin and comparable to b-lactams in the treatment of baceremic S. aureus infections. The bacteriostatic agents, quinupristin/dalfopristin (a streptogramin) and linezolid (an oxazolidinone), appear to be no more effective than vancomycin for therapy of serious S. aureus infections.
It is advised in septic shock with a microbial load - driven pathogenesis a combination therapy during the hemodynamic stabilization and usually to organism identification. Once hemodynamic stabilizations is achieved, the microbial burden has been reduced to a subcritical threshold that should no longer leave the patient at risk for irreversible injury.
