1. Antimicrobial De-escalation and Discontinuation Protocols

Early narrowing or stopping of antibiotics based on clinical improvement and microbiology reduces resistance pressure, side effects, and cost. This is a cornerstone of modern antimicrobial stewardship.

1.1 Criteria for Stewardship-Driven De-escalation

• Documented pathogen with susceptibility profile available
• Hemodynamic stability: off vasopressors for ≥24 hours, with a Mean Arterial Pressure (MAP) ≥ 65 mm Hg
• Afebrile for ≥48 hours; White Blood Cell (WBC) count trending toward normal
• Source control achieved (e.g., abscess drainage, infected device removal)
• Adequate antimicrobial penetration at the site of infection

1.2 Streamlining Empiric Therapy Based on Culture Data

Once culture results are available, therapy should be tailored to be as specific and safe as possible.

• Switch to the narrowest-spectrum agent active against the identified pathogen.
• Eliminate redundant combination coverage (e.g., stop piperacillin-tazobactam if also on vancomycin for a gram-positive infection).
• Optimize pharmacokinetics/pharmacodynamics (PK/PD): choose agents with a favorable half-life and free-drug exposure to maximize efficacy and minimize toxicity.

1.3 Duration Optimization and Discontinuation Guidelines

• Ventilator-associated/hospital-acquired pneumonia: 7–8 days
• Uncomplicated intra-abdominal infection: 4–7 days post-source control
• Uncomplicated UTIs: 5–7 days
• Bacteremia (non-Staphylococcus aureus): 7–14 days depending on source and clearance

2. Transition from Intravenous to Enteral Therapy

An early switch from intravenous (IV) to oral (PO) or enteral therapy reduces length of stay, minimizes line-associated complications (like CLABSI), and significantly cuts healthcare costs without compromising efficacy.

2.1 Candidate Agent Selection: Bioavailability & Interactions

The ideal agent for an IV-to-PO switch has high and predictable oral bioavailability. It’s also crucial to assess gastrointestinal function and potential drug interactions.

2.2 Enteral Access Device Considerations

• Tube Compatibility: Ensure tube diameter (≥ 8 Fr) is adequate for crushed tablets or liquid formulations to prevent clogging.
• Formulation Issues: Avoid syrups with high sorbitol content, which can cause diarrhea. Check for drug binding to enteral feed formulations (e.g., phenytoin, fluoroquinolones).

2.3 Institutional Algorithms and Automated Order Sets

Implementing system-level supports can hardwire best practices for IV-to-oral conversion.

• Define Switch Criteria: Patient is afebrile >24h, tolerating PO intake, has a stable/normalizing WBC, and is hemodynamically stable.
• Pharmacist-Driven Protocols: Empower pharmacists to automatically convert appropriate IV orders to PO equivalents based on an approved protocol.

3. Mitigating Post-ICU Syndrome (PICS)

Implement the ABCDEF bundle and early rehabilitation to reduce long-term physical, cognitive, and psychological sequelae after critical illness.

3.1 Identification of High-Risk Patients

Proactively identify patients at high risk for PICS to target interventions. Key risk factors include:

• Mechanical ventilation > 48 hours
• ICU-acquired delirium lasting > 2 days
• High cumulative doses of sedatives, especially benzodiazepines
• Diagnosis of sepsis or ARDS

3.2 Implementation of the ABCDEF Bundle

The ABCDEF bundle is a multicomponent, evidence-based strategy to improve ICU outcomes and reduce the incidence and severity of PICS.

3.3 Rehabilitation and Follow-Up Coordination

• Initiate Physical Therapy (PT) and Occupational Therapy (OT) consults while the patient is still in the ICU.
• Schedule a dedicated post-ICU clinic visit within 1–2 weeks after hospital discharge.
• Coordinate care plans with primary care physicians, rehabilitation services, and home health agencies.

4. Medication Reconciliation and Discharge Planning

A structured reconciliation and counseling process ensures continuity of therapy, prevents medication errors, and reinforces stewardship principles beyond the ICU walls.

4.1 Comprehensive Reconciliation Across Transitions of Care

This is a critical safety step to prevent errors as patients move from one level of care to another.

• Compare the active ICU medication list against new ward or discharge orders line-by-line.
• Verify indications, routes, doses, and especially durations for all antimicrobials.
• Confirm allergy history, check for new drug interactions, and ensure doses are adjusted for renal or hepatic function.

4.2 Patient and Caregiver Education Strategies

Empowering patients with knowledge is key to adherence and safety.

• Clearly explain the name, purpose, dosing schedule, and planned stop date for each medication.
• Use the “teach-back” method to confirm understanding.
• Provide clear, written materials, and highlight signs of toxicity and when to seek medical attention.

4.3 Outpatient Stewardship and Follow-Up Protocols

Stewardship doesn’t end at the hospital door. Ensure a safe handoff to the outpatient setting.

• Arrange for outpatient antibiotic follow-up (e.g., phone calls from a pharmacist or a scheduled clinic visit).
• Provide a clear outpatient prescription that explicitly states the stop date.
• Communicate stewardship recommendations, such as the reason for de-escalation and the planned duration, directly to the patient’s outpatient providers.