摘要:

“We know everything about antibiotics except how much to give,” Maxwell Finland once stated. Finally, with the proliferation of pharmacodynamics as a science, we are addressing the question of how much to give. We have moved from an era of more or less arbitrary antimicrobial dosage selection toward one characterized by evidence-based optimal dosing strategies. Optimizing antimicrobial therapy in critically ill patients is more than just the selection of a suitable dose for a particular patient. Optimizing therapy also involves the selection of an appropriate single or combination antibiotic regimen that is active against the suspected or documented pathogens at the site(s) of infection. The regimen should offer the fewest potential adverse events, and the duration of therapy should be the shortest possible so as not to encourage resistance. Dosing of the chosen regimen should reflect variables that are often ignored, such as the patient's weight and age. The new continuous renal replacement therapies are commonly used in the critical care unit and must be considered. Finally, the cost of the regimen should be considered, but not only the cost to purchase the chosen antimicrobial agent but the cost to administer it (ie, the cost of minibags or syringes, intravenous tubing, saline flushes [all multiplied by the number of times per day the drug is given]), and, most importantly, if the patient fails to respond to therapy, the cost necessary to re-treat the patient to bring about a cure. In this review, we discuss some of the principles required to optimize antimicrobial dosing and recently obtained data regarding its application to the critically ill patient.

ISSN:1070-5295    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

Central venous catheters are commonly used in the critical care setting. Unfortunately, their use is often associated with complications, including fatal infections. Making the diagnosis of central venous catheter infection can be difficult. Additionally, resistance among the more common organisms that cause catheter-related infection is increasing. However, our understanding of the pathogenesis of catheter infection is improving through examination of biofilms. Also, our ability to diagnose catheter-related infections more accurately is improving with new techniques. There is new hope for ruling out catheter-related infection before removal by several methods, including a rapid enzyme-linked immunosorbent assay and the use of time differential for microbial growth between blood cultures obtained from a peripheral site and the catheter itself. Prevention through the use of barrier techniques and antimicrobial-coated catheters has been demonstrated to be of value in reducing catheter-related infection with these devices.

ISSN:1070-5295    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

Surgical infections in the critically ill patient population are a significant cause of morbidity and mortality. Intra-abdominal and surgical soft-tissue infections are responsible for a significant proportion of the disease burden. Multiple risk factors have been identified that are associated with the development of surgical infections and subsequent morbidity and mortality. The microbiologic spectrum associated with these infections is broad and is determined by the site from which the infection arises and whether the infection is community acquired or nosocomial in origin. The diagnosis and management of these infections require a high index of suspicion, prompt surgical intervention, and adequate antibiotic therapy and resuscitation. Therefore, these infections present a challenge to the intensivist caring for a critically ill patient.

ISSN:1070-5295    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

Although several pneumonia severity criteria have been firmly established, the exact definition of severe community-acquired pneumonia (CAP) remains elusive. Mortality from CAP remains high, reaching 50% in some series. The particular role ofPseudomonas aeruginosaandAcinetobacterspp. in severe CAP has been defined more clearly. Microbial diagnosis in the individual patient remains a difficult task. Despite promising new diagnostic tools, concerns about possible mixed origins preclude a change from the currently advocated broad-spectrum approach of antimicrobial treatment. Although there is some evidence that guidelines may optimize outcomes, their role in limiting the spread of resistance has only recently received attention. Finally, although there are promising data on the use of noninvasive positive pressure ventilation to treat pneumonia in patients without chronic obstructive pulmonary disease, its place in the management of acute respiratory failure remains to be defined in randomized studies.

ISSN:1070-5295    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

Recent studies have contributed to our understanding of the risk factors and the impact of nosocomial infections in the ICU, allowing a more rational approach to the prevention of such infections. Ventilator-associated pneumonia, bloodstream infections, and outbreaks all occur in the presence of artificial devices. High antibiotic pressure, prolonged hosp\italization, and the presence of comorbidities facilitate the selection of multiresistant strains in the ICU setting. In clinical practice, prevention is the more effective investment to reduce costs. Potential measures of control should focus on the patient, the microorganisms, and the device. A number of recent studies addressing these issues have been published and will be reviewed in this article.

ISSN:1070-5295    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

An estimated 750,000 cases of severe sepsis occur annually in the United States, and the mortality rate is about 30%. As a condition that disproportionately affects the elderly and is related to invasive and immunosuppressive healthcare, increases in the frequency of sepsis are anticipated. The complex pathophysiology of sepsis encompasses the interplay of pro- and anti-inflammatory mediators, activated circulating and resident inflammatory cells, disrupted coagulation, endothelial activation and injury, vasodilatation and vascular hyporesponsiveness to vasoactive mediators, cardiac dysfunction, and cellular dysoxia. Current management of severe sepsis includes eradication of infection through source control and antimicrobial therapy, aggressive and targeted shock resuscitation that includes fluid administration, correction of anemia, vasopressor support, modest inotropic therapy, infusion of human recombinant activated protein C to selected patients, and compulsive supportive care to manage organ dysfunction and to avoid complications.

ISSN:1070-5295    

出版商:OVID    

年代:2002

数据来源: OVID

ISSN:1070-5295    

出版商:OVID    

年代:2002

数据来源: OVID