1. Weaning and De-escalation Protocols

As patients with intra-abdominal infections stabilize, the systematic reduction of life-sustaining therapies is crucial to minimize complications and support recovery.

A. Mechanical Ventilation Weaning Criteria

• FiO₂ ≤ 40% and PEEP ≤ 8 cm H₂O
• PaO₂/FiO₂ ratio ≥ 150–200
• Presence of spontaneous breathing effort and a Rapid Shallow Breathing Index (RSBI) < 105 breaths/min/L
• Adequate mental status (alert and cooperative)
• Hemodynamic stability (minimal or no vasopressor support)

B. Vasopressor and Inotrope Tapering

• Taper norepinephrine by 0.01–0.05 µg/kg/min every 30–60 minutes once the mean arterial pressure (MAP) is consistently ≥ 65 mmHg and serum lactate is clearing.
• Wean dobutamine or other inotropes based on objective measures of cardiac performance, such as cardiac output, ScvO₂, or echocardiographic findings.
• Avoid abrupt discontinuation of any vasoactive agent to prevent rebound hypotension and hemodynamic instability.

C. Algorithm for Antimicrobial De-escalation

1. Reassess at 48–72 Hours: After initial source control, re-evaluate the patient’s clinical status. Key indicators for de-escalation include being afebrile for ≥24 hours and a normalizing white blood cell count.
2. Review Microbiology Data: Examine all available culture and susceptibility reports to identify the causative pathogen(s) and their sensitivities.
3. Narrow the Spectrum: Switch from broad-spectrum empirical therapy to a narrower, pathogen-directed agent. Ensure that anaerobic coverage is retained if the source of infection warrants it.
4. Transition to Short-Course Therapy: For uncomplicated intra-abdominal infections with adequate source control, a total antibiotic course of approximately 4 days is often sufficient.
5. Engage Stewardship: Collaborate with the Antimicrobial Stewardship Program (ASP) for guidance on optimal agent selection, dose adjustments, and monitoring for resistance.

2. Conversion from Intravenous to Enteral Medications

Once gastrointestinal function returns, converting suitable agents to enteral routes promotes patient mobility, lowers healthcare costs, and reduces the risk of central line-associated bloodstream infections.

A. Assessing Gastrointestinal Readiness

• Clinical signs of returning gut motility, such as bowel sounds, passing of flatus, or bowel movements.
• Demonstrated tolerance of enteral nutrition without high gastric residual volumes (GRV < 200 mL).
• Absence of significant nausea, vomiting, or signs of ileus.
• Stable hemodynamics without recent escalation of vasopressor support.

B. Pharmacokinetic Considerations for Conversion

• Altered Absorption: Be aware that gut edema, hypoperfusion, or concurrent enteral nutrition can alter drug absorption.
• Bioavailability: Prioritize agents with high and predictable oral bioavailability (e.g., fluoroquinolones, linezolid, metronidazole).
• Formulations: Avoid crushing and administering extended-release or enteric-coated formulations via feeding tubes.
• Interactions: Check for significant drug-nutrient interactions (e.g., chelation of quinolones by divalent cations in feeds).

C. Selection and Dosing of Enteral Equivalents

3. Post-ICU Syndrome (PICS) Prevention

The ABCDEF bundle is a multidisciplinary, evidence-based strategy designed to mitigate the long-term physical, cognitive, and psychological impairments that can follow critical illness.

A. Identifying High-Risk Patients for PICS

• Mechanical ventilation for more than 48 hours.
• Exposure to deep or prolonged sedation, especially with benzodiazepines.
• Diagnosis of sepsis or severe intra-abdominal infection.
• Advanced age or pre-existing cognitive or functional impairments.

B. Implementing the ABCDEF Bundle

1. Assess, Prevent, and Manage Pain: Regularly assess pain using validated scales (e.g., CPOT for non-verbal patients, NRS for verbal patients) and treat with a multimodal approach.
2. Both SAT and SBT: Conduct daily Spontaneous Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT) to minimize sedation and ventilation duration.
3. Choice of Analgesia and Sedation: Prefer non-benzodiazepine sedatives like propofol or dexmedetomidine to reduce the incidence and duration of delirium.
4. Delirium Monitoring and Management: Screen for delirium at least twice daily using the CAM-ICU. Manage with non-pharmacologic interventions like reorientation, sleep protocols, and early mobility.
5. Early Mobility and Exercise: Progress from passive range-of-motion to active exercises and ambulation as soon as the patient is able. This counteracts ICU-acquired weakness.
6. Family Engagement and Empowerment: Involve caregivers in daily rounds, care planning, and patient reorientation. Educated and engaged families are a key component of recovery.

4. Medication Reconciliation and Discharge Planning

Pharmacist-led medication reconciliation and structured, multidisciplinary handoffs are critical interventions to lower the risk of medication errors and preventable hospital readmissions.

A. Comprehensive Medication Review

A meticulous review process should compare the patient’s pre-admission medication list, all inpatient therapies, and the planned discharge regimen. Pay special attention to:

• Antimicrobials: Clearly define the indication, agent, and total duration of therapy.
• Immunosuppressives: Reconcile doses and ensure continuity for transplant or autoimmune patients.
• Chronic Therapies: Verify doses of high-risk medications like anticoagulants, antihypertensives, and antidiabetic agents that may have been adjusted during the ICU stay.

B. Patient and Caregiver Education

• Utilize the teach-back method to confirm the patient and/or caregiver understands the purpose, dose, schedule, and key side effects of each medication.
• Provide clear, written instructions, including a simplified medication schedule and a plan for any required follow-up laboratory monitoring or appointments.

C. Structured Handoff Communication

Use a standardized format like SBAR (Situation, Background, Assessment, Recommendation) for all verbal and written handoffs to outpatient providers, home health agencies, or receiving facilities. The handoff must include:

• The original source of infection and summary of the hospital course.
• Final culture results and susceptibilities.
• The complete antibiotic plan, including start and stop dates.
• A list of any pending tests or follow-up actions.

5. Pharmacotherapy Considerations in Transition

This section summarizes key pharmacotherapy decisions during the transition from acute critical care to recovery.

Editor’s Note: Detailed protocols for analgesic/sedative tapering, duration of prophylactic therapies (VTE, stress ulcer), and the use of clinical decision tools are active areas of research and institutional protocol development. Clinicians should refer to local guidelines.