We spend a lot of time obsessing over the finer details of critical care: which fluid is best? which vasopressor is best? will another liter of fluid help? These details are important, but for a septic patient something more important than any of these details is choosing the right antibiotic(s). In septic shock, source control and correct antibiotic selection are probably the two variables most strongly related to survival.
This chapter attempts to lay out salient properties of antibiotics commonly used in critically ill patients. It's intended largely as a reference, for future exploration of various infectious diseases.
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The IBCC chapter is located here.
- The podcast & comments are below.
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Josh is the creator of PulmCrit.org. He is an associate professor of Pulmonary and Critical Care Medicine at the University of Vermont.
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Thank you for this well-written overview! I work in a internal medicine/EM/ICU setting in Scandinavia. Our main cephalosporin used in empiric treatment in both grampos and gramneg infections is cefotaxime. We have a very low rate of MRSA but a emerging problem with ESBL.
Would be interesting to see your thoughts on cefotaxime added to the list!
Sorry, I don’t have any experience with cefotaxime. From what I read, it’s extremely similar to ceftriaxone (a non-pseudomonal G3 cephalosporin). It’s tough to comment on its use with more knowledge of local antibiograms. Cefotaxime will miss pseudomonas and species with inducible AmpC gene (e.g. enterobacter), so it’s not bulletproof as empiric sepsis therapy but overall it is an excellent antibiotic.
Ceftriaxone is particularly notorious for inducing resistance, especially when underdosed. Its’ enterohepatic cycling metabolism that makes ceftriaxone so attractive to use in a wide range of patients also works to our detriment if the dose or interval is inadequate for body weight and/or type of infection. In (very) short, if the initial dose is inadequate or if drug levels are subtherapeutic for a good amount of the dosing interval, a greater proportion of time is spent within pathogens’ mutant selection window. So while highly susceptible isolates are probably being killed, the population of resistant isolates is left to thrive in… Read more »
Melville David
Worth the time and additional review. Thank you for sharing your clinical experience and scholarship!
Wonderful post. Anyway you guys can link this to the actual podcast? There isn’t a link attached for antibiotics under the IBCC table of contents. Had to dig a little to find this. Thank you
sorry I just added the link to the IBCC table of contents.
What do you recommend for Hospital-Acquired Uro-Sepsis?
Excellent review. Thank you very much for sharing.
Hi Dr. Farkas! In the IBCC chapter, you wrote that ceftriaxone should be the first line agent for treating S.pneumoniae. Were you referring to this as an empiric therapy of infections largely but not exclusively caused by S.pneumoniae or as a directed therapy when S.pneumoniae has grown in cultures? Also, did you choose ceftriaxone over amoxicilin or penicillin because of local resistance factors at your hospital/unit or did you base this on some other type of evidence ? In my department, we immediately deescalate therapy to penicillin G iv, whenever a S.peumoniae grows in the sputum ou blood culture, in… Read more »
hi Josh , wonder post as always .
What’s ur opinion on cefoperzone sulbactum. Why it’s not included in your list ?