Albumina En El Manejo De Shock Septico

REVIEW ARTICLE

Antibiotic therapy in patients with septic shock
Julien Textoris, Sandrine Wiramus, Claude Martin and Marc Leone
The management of a patient with severe sepsis is first to diagnose the infection, to collect samples immediately after diagnosis and to initiate promptly broad-spectrum antibiotic treatment. The choice of empirical antimicrobial therapy should be based on hostcharacteristics, site of infection, local ecology and the pharmacokinetics and pharmacodynamics of the antibiotics. In severe infection, guidelines recommend the use of a combination of antibiotics. After results of cultures are obtained, treatment should be re-evaluated to either de-escalate or escalate the antibiotics. This is associated with optimal costs, decreased incidence of superinfection andreduced development of antimicrobial resistance. All these steps should be based on written protocols, and compliance to these protocols should be monitored continuously in order to detect violations and implement corrective procedures. Eur J Anaesthesiol 2011;28:318–324
Published online 4 April 2011 Keywords: antibiotic, de-escalation, empirical, sepsis

Introduction
Empirical antimicrobialtherapy refers to the initiation of treatment prior to determination of a firm diagnosis. It is most often used when antibiotics are given to a patient before the specific micro-organism causing an infection is known. This is always the case in septic shock patients. As stated elsewhere, this therapy ranges from ‘derived from experiment and observation rather than theory’ at one extreme, to‘relying on medical quackery or uninfluenced by pathology or clinical tools’ at the other.1 Inappropriate empirical antimicrobial therapy is defined as the absence of antimicrobial agents directed against a specific class of micro-organisms and the administration of an antimicrobial agent to which the micro-organism responsible for infection was resistant. ‘Broad-spectrum antibiotics’ refers to antibioticswith activity against Pseudomonas aeruginosa, including imipenem-cilastatin, piperacillin-tazobactam, ceftazidime or ciprofloxacin. Limited-spectrum antibiotics will only refer to b-lactam antibiotics without activity against P. aeruginosa (essentially, ceftriaxone and amoxicillin-clavulanate).2

delay is associated with increased mortality and morbidity6 and carers should not wait for theresults of microbiological culture before introducing antibiotics in these groups of patients. The selection of initial antibiotic therapy is based on the risk factors for specific pathogens, modified by knowledge of local patterns of antibiotic resistance and organism prevalence.7 This treatment should be efficient against the bacteria involved in the suspected infection. Indeed, inappropriate empiricalantibiotic therapy is widespread and associated with increased mortality in critically ill patients. For instance, increased mortality was seen in patients treated with empirical piperacillintazobactam therapy and infected by P. aeruginosa bacteraemia due to isolates with reduced piperacillintazobactam susceptibility.8 The challenge is to provide an appropriate therapy without anymicrobiological documentation. In this setting, adherence to guidelines makes it possible to administer empirical antibiotic treatments effective against the most probable pathogens responsible for the potential infection.9 A recent study showed that adherence to standard operating procedures is associated with a shorter duration of treatment of pneumonia, a shorter duration of mechanical ventilation and ashorter ICU stay.10 Barriers to physicians’ adherence to guidelines include awareness, familiarity, agreement with the guideline, belief that one can actually perform an appropriate behaviour, outcome expectancy (the expectation that a given behaviour will lead to a particular consequence), the ability to overcome the inertia of previous practice and the absence of external barriers to follow...