Empiric antimicrobial therapy for severe sepsis in the intensive care unit: In early, hit hard, out early

Summary Sepsis is becoming more common in hospital patients and, despite developments in management, the morbidity and mortality of severe sepsis is still significant. Early, appropriate antimicrobial therapy has a significant positive effect on outcome and should be a priority in the management of these patients. This means treating empirically with broad-spectrum antimicrobials until the pathogen is identified. Balancing this is the need to avoid increasing antimicrobial resistance which has been shown to be proportional to antimicrobial use. While every effort should be made not to fail individual patients by inadequately treating their sepsis, it is important to minimize resistance by avoiding unnecessary and excessive antimicrobial use. Traditionally, empiric treatment has involved starting with a narrow antimicrobial spectrum and escalating it as culture results become known. Current opinion, however, is veering towards initiating empiric therapy as soon as possible with broad-spectrum antimicrobials, narrowing the spectrum once the organism is identified (de-escalation), and limiting duration of therapy to the minimum effective period. This approach improves outcome and controls antimicrobial resistance. Many of the recommendations on this subject are not supported by high level evidence. Much of the research has been done on hospital and ventilator acquired pneumonia. For the purposes of this paper we are assuming that these findings have relevance to other forms of sepsis. This review of some of the current literature attempts to clarify antimicrobial issues for the Intensive Care SHO or registrar dealing with the onset of severe sepsis in critically ill adults.