Antimicrobial Stewardship in Sepsis Management

Introduction to Antimicrobial Stewardship

Antimicrobial regimens should be reassessed daily for potential de-escalation to prevent resistance development, reduce toxicity, and minimize costs, as recommended by the Surviving Sepsis Campaign guidelines 1
Antimicrobial stewardship requires continuous evaluation of the need for and appropriateness of antibiotics, with decisions based on comprehensive clinical evaluation and clinician judgment, rather than isolated laboratory values, according to the Surviving Sepsis Campaign and World Journal of Emergency Surgery guidelines 1, 2

Procalcitonin (PCT) has been suggested as a novel biomarker that may be useful in guiding therapeutic decision making in sepsis management, particularly in patients with ongoing or persistent infections 2
Elevated white blood cell (WBC) counts alone are not a sufficient indication for antibiotics, but rather clinical justifications including disease manifestations, severity, radiographic findings, and other laboratory data should be considered, as recommended by the American College of Microbiology 3
The following biomarkers may indicate bacterial infection:

Critically ill patients, especially those requiring ICU admission or mechanical ventilation, have a higher risk of bacterial infection and should consider empiric antibiotics with elevated WBC, especially if accompanied by fever or hypothermia, tachypnea, tachycardia, or signs of organ dysfunction 3
Non-critically ill patients should not start antibiotics based on WBC elevation alone, but rather perform a comprehensive microbiologic workup before starting antibiotics 3, 4
Recommendations are against routine antibiotics in COVID-19 patients unless critically ill or with specific clinical justifications 3, 4

Overreliance on biomarkers alone to decide on antibiotic therapy leads to overuse 3, 4
Neglecting antibiotic stewardship contributes to antimicrobial resistance, and inappropriate antibiotic use should be avoided 3, 4
Withholding antibiotics until diagnostic results are available (4-8 hours) is acceptable for less severe infectious syndromes 4
Avoiding unnecessary antibiotic escalation is crucial to prevent antimicrobial resistance and colonization with resistant organisms, as recommended by the American College of Surgeons and the Journal of Microbiology, Immunology and Infection guidelines 3, 5

WBC elevation is common and often non-infectious in the first 48 hours after surgery, with a higher likelihood of representing infection 4+ days post-op 6, 7
The timing of WBC elevation should be considered when evaluating the likelihood of infection, as recommended by the Infectious Diseases Society of America 6, 7
If the surgical site appears normal and there is no systemic illness, no antibiotic escalation is needed, and continued monitoring is recommended, according to the World Journal of Emergency Surgery guidelines 5
If the surgical site shows concerning signs and systemic illness is present, obtaining appropriate cultures before starting or changing antibiotics and considering surgical site opening or drainage is indicated, as recommended by the Clinical Infectious Diseases guidelines 6

Diagnostic investigation is warranted in cases of persistent unexplained leukocytosis without other signs of infection, according to the World Journal of Emergency Surgery guidelines 5
Persistent signs of infection beyond 7 days of antibiotic treatment warrant diagnostic investigation, according to the World Journal of Emergency Surgery guidelines 5
Inappropriate initial antibiotic therapy in critically ill surgical patients with bacteremia is associated with worse outcomes, highlighting the importance of proper antibiotic selection and timing 5