I. Pharmacotherapy De-escalation and Route Conversion

A. Antibiotic De-escalation

Short summary: Narrow broad-spectrum antibiotics based on culture results and clinical response to reduce toxicity and resistance.

Mechanism & Rationale:

• Reduce selective pressure and adverse events by limiting spectrum once pathogen identified.
• Align therapy duration with source control milestones.

Agent Selection:

• Step down from carbapenems to β-lactam/β-lactamase inhibitors when Enterobacterales susceptible.
• Transition to oral agents (e.g., levofloxacin, trimethoprim-sulfamethoxazole) if bioavailability ≥70% and GI tract functional.

Dosing & Titration:

• Adjust frequency based on renal/hepatic recovery and normalized volume of distribution.
• Consider extended or continuous infusions for time-dependent β-lactams in critically ill.

Monitoring Parameters:

• Clinical: afebrile ≥48 hours, hemodynamic stability, wound assessment.
• Laboratory: leukocyte count, C-reactive protein, procalcitonin trends.
• Organ function: creatinine clearance, liver enzymes.

Contraindications & Cautions:

• Persisting sepsis, inadequate source control, high-output proximal fistula.
• Drug–drug interactions (e.g., QT prolongation with fluoroquinolones).

Advantages vs Disadvantages:

• Advantages: fewer side effects, lower cost, shorter hospital stay.
• Disadvantages: risk of relapse if de-escalated prematurely.

Clinical Decision Points:

• Trigger de-escalation when afebrile, procalcitonin <0.5 ng/mL, and negative imaging for abscess.

B. Conversion from IV to Enteral Medications

Short summary: Transition to enteral route lowers line-associated risks and facilitates discharge but requires GI functional assessment.

Assess Enteral Access & Fistula Location:

• Confirm tube tip position distal to fistula output site via imaging or endoscopy.
• Distinguish proximal (duodenal/jejunal) vs distal (ileal/colonic) fistulas for absorption feasibility.

Agent Selection & Formulation:

• Prefer liquid formulations; use crushed tablets only if stable in suspension.
• Avoid drugs with narrow therapeutic index or known instability (e.g., certain carbapenems).

PK/PD Considerations:

• Adjust doses for reduced bioavailability; monitor TDM for phenytoin, valproic acid, vancomycin.
• Be aware of feed–drug interactions (e.g., fluoroquinolones, tetracyclines chelation).

Dosing Adjustments & Administration:

• Flush tube before/after each dose; hold feeds 1 hour before and after administration for optimal absorption.

Monitoring Efficacy & Safety:

• Clinical outcomes: infection resolution, symptom control.
• Lab levels: drug concentrations when available.

II. Weaning Parenteral Nutrition

A. Criteria for Tapering

• Demonstrated intestinal function: enteral intake ≥50% of requirements for 48 hours.
• Fistula output <200 mL/day for distal fistulas; no signs of malabsorption.
• Stable electrolytes and glycemic control off TPN.

B. Stepwise Tapering Protocols

• Reduce total volume and calories by 10–20% every 2–3 days.
• Maintain protein intake (1.2–1.5 g/kg/day) to support healing.
• Implement overnight PN cycling (e.g., 12–14 h) to encourage daytime oral/enteral intake.
• Coordinate with dietitian for incremental enteral formula advancement (elemental → semi-elemental → standard).

C. Pitfalls & Monitoring

• Refeeding syndrome: monitor phosphate, magnesium, potassium daily during first week.
• Hypoglycemia risk during PN discontinuation—check glucose pre- and post-taper.
• Ongoing micronutrient losses—supplement trace elements and vitamins until 1 week post-transition.

III. Post-ICU Syndrome (PICS) Mitigation

A. Identification of High-Risk Patients

Risk factors include:

• Age >65 years
• Baseline frailty
• Mechanical ventilation >48 hours
• Deep sedation
• Sepsis
• High cumulative opioid/benzodiazepine exposure

B. ABCDEF Bundle Implementation

The ABCDEF bundle is a multicomponent strategy to reduce PICS, improve outcomes, and humanize care in the ICU:

C. Pharmacist-Led Interventions

• Optimize sedation: minimize deliriogenic agents; use RASS target –1 to 0.
• Analgesic planning: scheduled acetaminophen, NSAIDs, consider ketamine infusion for opioid reduction.
• Sleep promotion: melatonin 3–5 mg nightly; cluster care to minimize night-time disruptions.

IV. Medication Reconciliation and Discharge Counseling

A. Comprehensive Medication Reconciliation

• Verify inpatient therapies vs pre-admission list; resolve omissions, duplications, and dosing errors.
• Engage multidisciplinary team (nursing, pharmacy, physician) to confirm routes and indications.
• Highlight drugs requiring monitoring (e.g., warfarin, anticonvulsants, immunosuppressants).

B. Discharge Counseling Plan

• Educate on medication timing relative to feeds, infusion pump use, and line care.
• Provide written instructions on signs of dehydration, electrolyte imbalance, or infection.
• Coordinate outpatient parenteral nutrition (OPAT/OPN) services if needed; schedule home health nursing.
• Teach ostomy and wound care protocols; use teach-back method for patient/caregiver.

C. Follow-Up and Monitoring

• Arrange laboratory monitoring: electrolytes, renal/hepatic panels, nutritional markers weekly for first month.
• Schedule telehealth or in-person visits at 1 and 4 weeks post-discharge with pharmacist and dietitian.
• Ensure linkage to wound care and nutrition support clinics for long-term surveillance.