monotherapy for cSSTI and intra-abdominal infections. There are also concerns about
emerging resistance.
Colistin use is seeing a reemergence as ICUs battle increasingly resistantAcinetobacter
andPseudomonas. Its utility is limited by its significant risk of nephrotoxicity.
ANTIBIOTIC CYCLING
We will make only brief mention of the concept of antibiotic cycling, since this practice
continues to be of unproven merit at the time of this writing. Antibiotic cycling involves
rotating the standard empiric therapy regimens in an ICU, usually every several months, with
the aim of reducing the emergence of drug-resistant pathogens. Several studies conducted
around the turn of the 21st century suggested great promise to this approach. In 2001,
Raymond and colleagues reported that rotating empiric regimens even at one-year intervals
might be beneficial (37). However, questions remained, and it was currently felt that the
evidence is insufficient to recommend this practice as a routine measure (8,38).
SUMMARY
In light of the continuous evolution of drug-resistant and MDR pathogens, limited numbers of
anti-infectives in the pipeline, and an increasing severity of illness among the ICU patient
population, special attention toward appropriate antibiotic selection is of utmost importance.
As we discussed in this chapter, prompt empirical therapy based on host factors and local
epidemiological data reduces morbidity and mortality; however, clinicians must be mindful
that their duty as stewards of our antimicrobial armamentarium does not end with the initial
selection. Providers must reassess antibiotic regimens on a regular basis for early de-escalation
to definitive therapy, dose optimization, compatibilities, untoward drug events, intravenous to
oral conversions, and importantly, therapy duration.
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