SEVERE INFECTIONS: Edited by Jean-François TimsitBest practice: antibiotic decision-making in ICUsBrink, Adrian Johna; Richards, GuybAuthor Information aDivision of Medical Microbiology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa bDepartment of Critical Care Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa Correspondence to Adrian John Brink, Professor and Head of the Division of Medical Microbiology, 5th floor, Suite 5.28, Falmouth building, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, 7925, Cape Town, South Africa. Tel: +27 214066083; +27 825737330; e-mail: [email protected] Current Opinion in Critical Care: October 2020 - Volume 26 - Issue 5 - p 478-488 doi: 10.1097/MCC.0000000000000752 Buy Metrics Abstract Purpose of review A major challenge in the ICU is optimization of antibiotic use. This review assesses current understanding of core best practices supporting and promoting astute antibiotic decision-making. Recent findings Limiting exposure to the shortest effective duration is the cornerstone of antibiotic decision-making. The decision to initiate antibiotics should include assessment of risk for resistance. This requires synthesis of patient-level data and environmental factors to determine whether delayed initiation could be considered in some patients with suspected sepsis until sensitivity data is available. Until improved stratification scores and clinically meaningful cut-off values to identify MDR are available and externally validated, decisions as to which empiric antibiotic is used should rely on syndromic antibiograms and institutional guidance. Optimization of initial and maintenance doses is another enabler of enhanced outcome. Stewardship practices must be streamlined by re-assessment to minimize negative effects, such as a potential increase in duration of therapy and increased risk of collateral damage from exposure to multiple, sequential antibiotics that may ensue from de-escalation. Summary Multiple challenges and research priorities for antibiotic optimization remain; however, the best stewardship practices should be identified and entrenched in daily practice. Reducing unnecessary exposure remains a vital strategy to limit resistance development. Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.