AUG 08, 2017 | JESSICA BURCHETTE, PHARMD, BCPS, AND DAVID CLUCK, PHARMD, BCPS, AAHIVP
The concept of “double coverage” with antimicrobials in critically ill patients has been the subject of debate for many years and has become essentially clinician-specific. The 2016 update suggests the use of empiric combination therapy in patients with septic shock; however, the evidence for this recommendation is weak, with little support found in randomized controlled clinical trials. The importance of combination therapy is emphasized by the heightened risk of mortality with inadequate coverage.13
Clinicians may experience a certain sense of comfort in initiating empiric combination antimicrobial therapy in any patient, not just in those who are critically ill. However, this sense can be fallacious and should be offset somewhat by the questionable benefit that double coverage imparts to patients who have pathogens that are resistant to multiple drugs. Organisms that are resistant to beta-lactams are also likely to be resistant to a second, added agent, such as a fluoroquinolone or an aminoglycoside; even if the resistance is not present, the second agent may simply provide no benefit.14
Although many attempts have been made to address this question, the resulting data have provided mixed answers and the need for empiric combination therapy in all critically ill patients remains controversial.
Despite recent data from trials that suggest EGDT is no better than usual care, the evolution of care for septic patients continues to improve. However, challenges remain, particularly with drug-resistant pathogens and the relative dearth of new agents. Fortunately, ongoing clinical trials will continue to shed light on areas of controversy in this most recent iteration of the guidelines, and certainly there is promise in the progress being made.
Dr. Burchette graduated from Gatton College of Pharmacy in 2010 before completing 2 years of postgraduate residency. She has been a faculty member for 5 years, with a didactic emphasis in pulmonary and critical care PharmD coursework. Clinically, she works in the acute care setting with an academic family medicine team. She is an active member of SIDP.
Dr. Cluck is an assistant professor in the Department of Pharmacy Practice at East Tennessee State University (ETSU) Gatton College of Pharmacy. He maintains a clinical pharmacy practice in infectious diseases at Johnston Memorial Hospital in Abingdon, Virginia, as well as a weekly outpatient HIV clinic with the ETSU HIV Center of Excellence. He is also an active member of SIDP, ACCP, ASHP, IDSA, and AAHIVM.
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