Controversies in the antibiotic management of critically ill patients

Preventing infection, managing antibiotics, and controlling antibiotic resi stance are integral to the daily practice of any physician caring for criti cally ill patients. Many controversies remain in this area, but improving o ur ability to manage anti-infective drugs is likely to be a determinant fac tor on the outcome of critically ill patients. Several measures to prevent nosocomial infections are available, including selective digestive decontam ination (SDD) and antibiotic-coated catheters, but a careful assessment of the effect of these strategies upon resistance is needed before considering their extensive use in the ICU. Antibiotic therapy of severely infected pa tients can be considered as a two-step contract, the first part of which co nsists in providing individual patients with the best antibiotic strategy. This raises important, although often unsolved, questions regarding the dos e, the interest of combining two antibiotics, and the length of therapy. Th e second part of the contract concerns not only individual patients but the community. Reassessment of the initial therapy is mandatory to avoid prolo nged and unnecessary usage of broad spectrum and costly antibiotics, which increase resistance pressure. In many cases, antibiotics can be either stop ped or changed after 2 or 3 days.