Risk Factors for Amoxicillin-Clavulanate Resistance in Community-Onset Urinary Tract Infections Caused by Escherichia coli or Klebsiella pneumoniae: The Role of Prior Exposure to Fluoroquinolones.

BACKGROUND: High rates of amoxicillin-clavulanate (AMC) resistance among Enterobacterales isolated from urinary tract infections (UTIs) were observed in our area. The aim of this study was to identify risk factors associated with AMC resistance in patients with community-onset UTI in emergency departments (EDs). METHODS: A retrospective study was performed of all ED patients with positive urine cultures for Escherichia coli or Klebsiella pneumoniae in a Spanish tertiary-care hospital. RESULTS: 330 urine cultures in all were included: 261 (79.1%) for E. coli and 69 (20.90%) for K. pneumonia. Rates of AMC resistance were 14.94% and 34.78%, respectively. UTI was clinically confirmed in 212 (64.24%) cases. Previous antimicrobial exposure was independently associated with AMC resistance development in E. coli and K. pneumoniae urinary isolates (OR = 2.94, 95% CI = 1.55-5.58). Analyses of infected patients revealed that previous exposure to fluoroquinolones (OR = 3.33, 95% CI = 1.10-10.12, p = 0.034) and to AMC (OR = 5.68, 95% CI = 1.97-16.44, p = 0.001) was significantly associated with isolation of AMC-resistant strains. CONCLUSIONS: Prior antibiotic exposure, particularly to AMC or fluoroquinolones, was the only independent risk factor associated with development of AMC resistance in E. coli and K. pneumoniae urinary isolates from patients attending the ED.

Evolution of Antimicrobial Consumption During the First Wave of COVID-19 Pandemic.

Background: The first wave of COVID-19 pandemic may have significantly impacted antimicrobial consumption in hospitals. The objective of this study was to assess the evolution of antimicrobial consumption during this period. Methods: A retrospective quasi-experimental before-after study was conducted in a Spanish tertiary care hospital. The study compared two periods: pre-pandemic, from January 2018 to February 2020, and during the COVID-19 pandemic from March to June 2020. Antimicrobial consumption was analyzed monthly as defined daily doses (DDD)/100 bed-days and overall hospital and ICU consumption were evaluated. Results: An increase in the hospital consumption was noticed. Although only ceftaroline achieved statistical significance (p = 0.014), a rise was observed in most of the studied antimicrobials. A clear temporal pattern was detected. While an increase in ceftriaxone and azithromycin was observed during March, an increment in the consumption of daptomycin, carbapenems, linezolid, ceftaroline, novel cephalosporin/ß-lactamase inhibitors or triazoles during April-May was noticed. In the ICU, these findings were more evident, namely ceftriaxone (p = 0.029), carbapenems (p = 0.002), daptomycin (p = 0.002), azithromycin (p = 0.030), and linezolid (p = 0.011) but followed a similar temporal pattern. Conclusion: An increase in the antimicrobial consumption during the first wave of COVID-19 pandemic was noticed, especially in the ICU. Availability of updated protocols and antimicrobial stewardship programs are essential to optimize these outcomes.

Impact of adrenomedullin levels on clinical risk stratification and outcome in subarachnoid haemorrhage.

PURPOSE: To use classification tree analysis to identify risk factors for nonsurvival in a neurological patients with subarachnoid haemorrhage (SAH) and to propose a clinical model for predicting of mortality. METHODS: Prospective study of SAH admitted to a Critical Care Department and Stroke Unit over a 2-year period. Middle region of pro-ADM plasma levels (MR-proADM) was measured in EDTA plasma within the first 24 hours of hospital admission using the automatic immunofluorescence test. A regression tree was made to identify prognostic models for the development of mortality at 90 days. RESULTS: Ninety patients were included. The mean MR-proADM plasma value in the samples analysed was 0.78 ± 0.41 nmol/L. MR-proADM plasma levels were significantly associated with mortality at 90 days (1.05 ± 0.51 nmol/L vs 0.64 ± 0.25 nmol/L; P < .001). Regression tree analysis provided an algorithm based on the combined use of clinical variables and one biomarker allowing accurate mortality discrimination of three distinct subgroups with high risk of 90-day mortality ranged from 75% to 100% (AUC 0.9; 95% CI 0.83-0.98). CONCLUSIONS: The study established a model (APACHE II, MR-proADM and Hunt&Hess) to predict fatal outcomes in patients with SAH. The proposed decision-making algorithm may help identify patients with a high risk of mortality.

A Before-and-After Study of the Effectiveness of an Antimicrobial Stewardship Program in Critical Care.

We evaluated the use of antimicrobials expressed as defined daily doses (DDDs) per 1,000 patient days and days of therapy (DOT) per 100 occupied bed-days in a intensive care unit (ICU) of a general hospital in Barcelona, Spain, before and after implementation of an antimicrobial stewardship (AMS) program (2007 to 2010 versus 2011 to 2015). The quarterly costs of antimicrobials used in the ICU and its weight in the overall hospital costs of antimicrobials were calculated. The effect of the applied AMS program on DDDs and DOT time series data was analyzed by means of intervention time series analysis. A total of 5,002 patients were included (1,971 for the first [before] period and 3,031 for the second [after] period). The percentage of patients treated with one or more antimicrobials decreased from 88.6 to 77.2% (P < 0.001). DDDs decreased from 246.8 to 192.3 (mean difference, -54.5; P = 0.001) and DOT from 66.7 to 54.6 (mean difference, -12.1; P = 0.066). The mean cost per trimester decreased from €115,543 to €73,477 (mean difference, -42,065.4 euros; P < 0.001), and the percentage of ICU antimicrobials cost with respect to the total cost of hospital antimicrobials decreased from 28.5 to 22.8% (mean difference, -5.59; P = 0.023). Implementation of an AMS program in the ICU was associated with a marked reduction in the use of antimicrobials, with cost savings close to one million euros since its implementation. An AMS program can have a significant impact on optimizing antimicrobial use in critical care practice.

Ceftolozane-tazobactam for the treatment of ventilator-associated infections by colistin-resistant Pseudomonas aeruginosa / Ceftolozano-tazobactam en el tratamiento de infecciones respiratorias asociadas a ventilación mecánica por Pseudomonas aeruginosa resistente a colistina

The use of colistin for the treatment of multiresistant bacteria has led to the emergence of colistin-resistant strains of Gram-negative bacilli. Treatment of infections caused by these pan-drug-resistant bacteria is difficult owing to the paucity of effective antibiotics. We report two cases of ventilator-associated respiratory infection caused by pan-drug-resistant, colistin-resistant Pseudomonas aeruginosa that were successfully treated with ceftolozane-tazobactam (AU)

La utilización de colistina para el tratamiento de bacterias multirresistentes ha favorecido la aparición de cepas de bacilos gramnegativos resistentes a dicho antibiótico. El tratamiento de las infecciones producidas por estas bacterias panresistentes es difícil dada la escasez de antibióticos que se pueden emplear en esta situación. Se presentan dos pacientes con infecciones respiratorias relacionadas con ventilación mecánica producidas por una Pseudomonas aeruginosa panresistente y resistente a colistina que fueron tratadas con ceftolozano/tazobactam con buenos resultados (AU)

Evolución del consumo de antifúngicos en pacientes críticos. Estudio multicéntrico observacional, 2006-2010 / Trends in systemic antifungal use in critically ill patients. Multicenter observational study, 2006-2010

Hay poca información sobre el consumo de antifúngicos (AF) en pacientes críticos y las variaciones temporales desde la introducción de nuevos AF. Este consumo puede tener influencia en la aparición de resistencias. Métodos Estudio observacional prospectivo del consumo de AF sistémicos en pacientes ingresados en unidades de cuidados intensivos (UCI) españolas del registro ENVIN-HELICS durante los años 2006 a 2010. Se compara la utilización anual, el consumo según prescripciones y para infecciones intra-UCI, el calculado por tamaño de hospital y por 1.000 días de estancia. Resultados De 8.240 prescripciones de AF registradas, los AF más frecuentemente empleados fueron el fluconazol y la caspofungina (55 y 19,5%, respectivamente). Existió un incremento del consumo hasta el año 2008 y una estabilización posterior. Anualmente, se comprobó la disminución del uso de fluconazol y el crecimiento del consumo de equinocandinas. Predominó la utilización de fluconazol en hospitales de tamaño mediano con respecto a hospitales grandes (60,4% versus 53,3%; p=0,036), y lo contrario con respecto a la utilización de caspofungina (15,8% versus 21,8%; p<0,001). El fluconazol se empleó más precozmente (mediana desde el ingreso en UCI: 12 días) y durante un tiempo similar a otros AF (mediana: 8 días). El total de días de tratamiento fue de 39,51 días por 1.000 estancias, con predominio de fluconazol (21,48 días por 1.000 estancias).Conclusiones El fluconazol es el AF más utilizado en pacientes críticos en cualquiera de las indicaciones, aunque se constata un progresivo descenso en su consumo y un incremento proporcional del empleo de equinocandinas (AU)

Introduction: There are limited data about the use of antifungal agents (AF) in critically ill patients and treatment trends since the inclusion of the new generation AF. The use of these agents may have a significant influence on the development of new resistances. Methods: Observational prospective study of the systemic use of AF in patients admitted to Spanish intensive care units (ICU) participating in the ENVIN-HELICS register, from 2006 to 2010. The annual use, the indications that led to that use and, the intra-ICU infections, the AF employment related to the hospital size, and per 1000 patients/day, were compared. Results: Of the 8240 prescriptions for AF, fluconazole and caspofungin were the most often employed (55%and 19.5%, respectively). An increase in use was observed to the year 2008, with subsequent stabilisation. A decrease in the use of fluconazole and an increase in echinocandins consumption was observed overtime. As regards the intra-ICU infections, the AF were ordered empirically in 47.9% of the indications. Fluconazole was more frequently used in medium size hospitals than in the large ones (60.4% versus 53.3%;P = .036) and the opposite occurred in the case of caspofungin (15.8% versus 21.8%; P < .001). Fluconazole was more prematurely employed (median 12 days since ICU admission) and the duration of the therapy was similar to the other AF (median 8 days). The total therapy days were 39.51 per 1000 patient/day, with predominance in fluconazole use (21.48 per 1000 patients/day).Conclusions: Fluconazole is the most used antifungal agent in critically ill patients in any of the indications, although a progressive decrease in its use is observed, with a proportional increase in the use of echinocandins (AU)

[Analysis of treatments used in infections caused by gram-positive multiresistant cocci in critically ill patients admitted to the ICU]. / Análisis de los tratamientos utilizados en las infecciones por cocos grampositivos multirresistentes en pacientes críticos ingresados en UCI.

UNLABELLED: The appearance of new antimicrobials with activity against Gram-positive multiresistant cocci and knowledge of the limitations of glycopeptides has represented an important change in the use of these antibiotics. OBJECTIVE: To analyze at the national level changes in the use of antibiotics with specific activity against Gram-positive multiresistant cocci in critically ill patients admitted to the ICU as well as the characteristics of patients treated with these agents and the forms of administration. MATERIAL AND METHODS: Retrospective cohort study of patients admitted to the ICU for more than 24 hours between 2008 and 2010 in the ENVIN-HELICS national registry. Cases were defined as patients who had received one or more of the following antibiotics: vancomycin, teicoplanin, linezolid or daptomycin. The characteristics of patients who used one or more of these agents were compared with those treated with other antibiotics. Indications and forms of use of each antibiotic were assessed. Descriptive results are presented. RESULTS: A total of 45,757 patients, 27,982 (61.2%) of whom received 63,823 antimicrobials were included in the study. In 6,368 (13.9%) patients, one or more antibiotics specifically active against Gram-positive multiresistant cocci were given. There was a predominance of the use of vancomycin and linezolid and an important increase in the prescription of daptomycin (+320%) and linezolid (+22.4%). In more than 95% of cases, linezolid and daptomycin were prescribed for the treatment of infections, whereas vancomycin and teicoplanin were used for prophylaxis in 20-25% of cases. Between 75% and 80% of indications for treating infections, antibiotics were used empirically except for daptomycin which was used as a directed treatment in 43% of the cases. Only in one third of the indications for empirical treatment, susceptible microorganisms were identified (appropriate treatment). CONCLUSIONS: The use of antibiotics with activity against Gram-positive multiresistant cocci remained stable around 14% of all indications. The use of vancomycin and linezolid predominated and there was a clear trend towards an increase in the use of daptomycin and linezolid and a decrease in the use of glycopeptides. Empirical treatments were considered appropriate in only one third of cases.

[Trends in systemic antifungal use in critically ill patients. Multicenter observational study, 2006-2010]. / Evolución del consumo de antifúngicos en pacientes críticos. Estudio multicéntrico observacional, 2006-2010.

INTRODUCTION: There are limited data about the use of antifungal agents (AF) in critically ill patients and treatment trends since the inclusion of the new generation AF. The use of these agents may have a significant influence on the development of new resistances. METHODS: Observational prospective study of the systemic use of AF in patients admitted to Spanish intensive care units (ICU) participating in the ENVIN-HELICS register, from 2006 to 2010. The annual use, the indications that led to that use and, the intra-ICU infections, the AF employment related to the hospital size, and per 1000 patients/day, were compared. RESULTS: Of the 8240 prescriptions for AF, fluconazole and caspofungin were the most often employed (55% and 19.5%, respectively). An increase in use was observed to the year 2008, with subsequent stabilisation. A decrease in the use of fluconazole and an increase in echinocandins consumption was observed over time. As regards the intra-ICU infections, the AF were ordered empirically in 47.9% of the indications. Fluconazole was more frequently used in medium size hospitals than in the large ones (60.4% versus 53.3%; P=.036) and the opposite occurred in the case of caspofungin (15.8% versus 21.8%; P<.001). Fluconazole was more prematurely employed (median 12 days since ICU admission) and the duration of the therapy was similar to the other AF (median 8 days). The total therapy days were 39.51 per 1000 patient/day, with predominance in fluconazole use (21.48 per 1000 patients/day). CONCLUSIONS: Fluconazole is the most used antifungal agent in critically ill patients in any of the indications, although a progressive decrease in its use is observed, with a proportional increase in the use of echinocandins.

Análisis de los tratamientos utilizados en las infecciones por cocos grampositivos multirresistentes en pacientes críticos ingresados en UCI / Analysis of treatments used in infections caused by Gram-positive multiresistant cocci in critically ill patients admitted to the ICU

La aparición de nuevos antibióticos activos frentes a cocos grampositivos multirresistentes (CGP-MR) y el conocimiento de las limitaciones de los glucopéptidos ha supuesto un importante cambio en las tendencias de utilización de estos antibióticos. Objetivo. Analizar las variaciones a nivel nacional en el consumo de antibióticos activos de forma específica frente a CGP-MR en pacientes críticos ingresados en UCI así como las características de los pacientes que los utilizan, y sus formas de empleo. Material y métodos. Análisis retrospectivo, de cohortes que incluye los pacientes ingresados en UCI más de 24 horas entre los años 2008-2010 del registro ENVIN-HELICS. Se define como caso los pacientes que han recibido uno o más de los siguientes antibióticos: vancomicina, teicoplanina, linezolid o daptomicina. Se comparan las características de los pacientes que han utilizado uno o más de dichos antibióticos con los pacientes que han utilizado otros antibióticos. Se describen las indicaciones y formas de utilización de cada uno de ellos. Los resultados se presentan de forma descriptiva. Resultados. Se han incluido 45.757 pacientes de los que 27.982 (61,2%) han utilizado 63.823 antimicrobianos. En 6.368 (13,9%) pacientes se han utilizado uno o más antibióticos activos de forma selectiva frente a CGP-MR. Ha predominado la utilización de vancomicina y linezolid y se observa un importante incremento en la prescripción de daptomicina (+320%) y de linezolid (+22,4%). Mas del 95% de indicaciones de linezolid y daptomicina se realizaron para el tratamiento de infecciones mientras que vancomicina y teicoplanina se utilizó entre el 20-25% de los casos para profilaxis. Entre el 75-80% de las indicaciones de tratamiento se han realizado de forma empírica excepto con daptomicina que se ha utilizado de forma dirigida en el 43% de los casos. Sólo en una tercera parte de las indicaciones para tratamiento empírico se han identificado microorganismos susceptibles (tratamiento apropiado). Conclusiones. El empleo de antibióticos activos frente a CGP-MR se mantiene estable en torno al 14% del total de indicaciones. Existe un predominio en el uso de linezolid y vancomicina y una clara tendencia a incrementar el empleo de daptomicina y linezolid y a disminuir el uso de glucopéptidos. Sólo una tercera parte de los tratamientos empíricos con estos antibióticos se han valorado como apropiados(AU)

The appearance of new antimicrobials with activity against Gram-positive multiresistant cocci and knowledge of the limitations of glycopeptides has represented an important change in the use of these antibiotics. Objetive. To analyze at the national level changes in the use of antibiotics with specific activity against Gram-positive multiresistant cocci in critically ill patients admitted to the ICU as well as the characteristics of patients treated with these agents and the forms of administration. Material and methods. Retrospective cohort study of patients admitted to the ICU for more than 24 hours between 2008 and 2010 in the ENVIN-HELICS national registry. Cases were defined as patients who had received one or more of the following antibiotics: vancomycin, teicoplanin, linezolid or daptomycin. The characteristics of patients who used one or more of these agents were compared with those treated with other antibiotics. Indications and forms of use of each antibiotic were assessed. Descriptive results are presented. Results. A total of 45,757 patients, 27,982 (61.2%) of whom received 63,823 antimicrobials were included in the study. In 6,368 (13.9%) patients, one or more antibiotics specifically active against Gram-positive multiresistant cocci were given. There was a predominance of the use of vancomycin and linezolid and an important increase in the prescription of daptomycin (+320%) and linezolid (+22.4%). In more than 95% of cases, linezolid and daptomycin were prescribed for the treatment of infections, whereas vancomycin and teicoplanin were used for prophylaxis in 20-25% of cases. Between 75% and 80% of indications for treating infections, antibiotics were used empirically except for daptomycin which was used as a directed treatment in 43% of the cases. Only in one third of the indications for empirical treatment, susceptible microorganisms were identified (appropriate treatment). Conclusions. The use of antibiotics with activity against Gram-positive multiresistant cocci remained stable around 14% of all indications. The use of vancomycin and linezolid predominated and there was a clear trend towards an increase in the use of daptomycin and linezolid and a decrease in the use of glycopeptides. Empirical treatments were considered appropriate in only one third of cases(AU)

Daptomicina para el tratamiento de las infecciones por microorganismos grampositivos en el paciente crítico / Daptomycin for the treatment of Gram-positive microorganisms in the critically-ill patient

Introducción: Las infecciones por cocos grampositivos (CGP) multirresistentes han aumentado entre los pacientes críticos ingresados en unidades de cuidados intensivos (UCI). Su tratamiento ha experimentado cambios en los últimos años en relación con el mayor conocimiento de las limitaciones de los glucopéptidos y la aparición de nuevos antimicrobianos entre los que destaca la daptomicina. Objetivos: Describir las características de la daptomicina que justifican su empleo en pacientes críticos y presentar la información sobre la utilización de este antibiótico en pacientes ingresados en UCI españolas. Material y métodos: Se ha revisado la literatura científica de daptomicina para identificar las características que pueden favorecer la respuesta clínica en pacientes críticos. Para describir las indicaciones y las formas de uso de daptomicina en pacientes críticos, se ha analizado a los pacientes españoles ingresados en UCI del registro EUCORE. Resultados: Se han identificado como condiciones favorables: a) escasa respuesta sistémica manteniendo una elevada actividad bactericida, b) escaso impacto en la función renal, c) no precisar de monitorización plasmática, d) escasa selección de resistencias, y e) excelente tolerabilidad. Para valorar las indicaciones y la forma de uso en la UCI como se ha analizado a 122 pacientes del registro EUCORE. Indicaciones: bacteriemias (36,2%), infecciones complicadas de piel y partes blandas (27,6%) y endocarditis (19%). En las etiologías han predominado Staphylococcus aureus (26%), Staphylococcus epidermidis (25%) y otras especies de estafilococos coagulasa negativa (SCN) (12%). El tratamiento se ha administrado en el 85,7% de los casos en segunda línea (tratamiento de rescate). En 65 (52%) pacientes se utilizó una dosis de 6 mg/kg/día; la duración media de los tratamientos fue de 10,2 días. La eficacia clínica global fue del 73,7%. No se detectaron efectos adversos que obligaran a su retirada y en ningún caso se observó un incremento de la cifra de creatincinasa superior a 10 veces los valores iniciales. Conclusiones: Daptomicina es una nueva opción terapéutica que se debe considerar en el tratamiento de infecciones graves por CGP en pacientes críticos (AU)

Introduction. Infections caused by multiresistant Gram-positive cocci have increased among critically ill patients admitted to the intensive care unit (ICU). In the last few years, treatment of these infections has changed due to better knowledge of the limitations of glycopeptides and the introduction of novel antimicrobials, such as daptomycin. Objectives. To describe the characteristics of daptomycin that justify its administration in critically ill patients and to present data on the use of this antibiotic in patients admitted to Spanish ICUs. Material and method. We reviewed the literature on daptomycin to identify the characteristics that may favor clinical response in critically ill patients. To describe the indications and modalities of use in critically patients, information from the European Cubicin® Outcome Registry and Experience (EUCORE) database of Spanish patients admitted to the ICU was employed Results. The following favorable conditions were identified: a) scarce systemic response, maintaining high bactericidal activity, b) scarce impact on renal function, c) no requirement for monitoring of plasma levels, d) scarce selection of resistance, and d) excellent tolerability. To assess indications and the use of this agent in the ICU, 122 patients from the EUCORE database were analyzed. The indications were bacteremias (36.2%), complicated infections of the skin and soft tissues (27.6%), and endocarditis (19%). Prominent pathogens were Staphylococcus aureus (26%), S. epidermidis (25%), and other coagulase-negative staphylococci (12%). In 85.7% of patients, treatment was administered as second-line (rescue treatment). In 65 patients (52%), a dose of 6 mg/kg/day was used, with a mean treatment duration of 10.2 days. Overall clinical efficacy was 73.7%. No adverse effects leading to treatment withdrawal were recorded and no increases in creatine phosphokinase (CPK) levels greater than 10-fold the initial values were observed. Conclusions: Daptomycin is a novel therapeutic option to be considered in the treatment of severe infections caused by Gram-positive cocci in critically-ill patients (AU)

[Daptomycin for the treatment of Gram-positive microorganisms in the critically-ill patient]. / Daptomicina para el tratamiento de las infecciones por microorganismos grampositivos en el paciente crítico.

INTRODUCTION: Infections caused by multiresistant Gram-positive cocci have increased among critically ill patients admitted to the intensive care unit (ICU). In the last few years, treatment of these infections has changed due to better knowledge of the limitations of glycopeptides and the introduction of novel antimicrobials, such as daptomycin. OBJECTIVES: To describe the characteristics of daptomycin that justify its administration in critically ill patients and to present data on the use of this antibiotic in patients admitted to Spanish ICUs. MATERIAL AND METHOD: We reviewed the literature on daptomycin to identify the characteristics that may favor clinical response in critically ill patients. To describe the indications and modalities of use in critically patients, information from the European Cubicin(®) Outcome Registry and Experience (EUCORE) database of Spanish patients admitted to the ICU was employed. RESULTS: The following favorable conditions were identified: a) scarce systemic response, maintaining high bactericidal activity, b) scarce impact on renal function, c) no requirement for monitoring of plasma levels, d) scarce selection of resistance, and d) excellent tolerability. To assess indications and the use of this agent in the ICU, 122 patients from the EUCORE database were analyzed. The indications were bacteremias (36.2%), complicated infections of the skin and soft tissues (27.6%), and endocarditis (19%). Prominent pathogens were Staphylococcus aureus (26%), S. epidermidis (25%), and other coagulase-negative staphylococci (12%). In 85.7% of patients, treatment was administered as second-line (rescue treatment). In 65 patients (52%), a dose of 6 mg/kg/day was used, with a mean treatment duration of 10.2 days. Overall clinical efficacy was 73.7%. No adverse effects leading to treatment withdrawal were recorded and no increases in creatine phosphokinase (CPK) levels greater than 10-fold the initial values were observed. CONCLUSIONS: Daptomycin is a novel therapeutic option to be considered in the treatment of severe infections caused by Gram-positive cocci in critically-ill patients.

Gram-positive cocci infections in intensive care: guide to antibacterial selection.

The incidence of multiresistance in Gram-positive cocci causing infections in critically ill patients admitted to the intensive care unit (ICU) has increased notably in recent years. Thus, therapeutic proposals have been modified according to the emergence of multiresistant cocci and adapted to epidemiological markers of individual infectious processes, geographical variations of these markers, the availability of new antibacterials, and advances in the knowledge of pharmacokinetic and pharmacodynamic aspects of their use. The current management of critically ill patients should consider new therapeutic approaches, such as the "de-escalating strategy", which includes the administration of empirical antibacterials active against multiresistant pathogens followed by directed treatment based on unequivocal data from antibacterial-susceptibility testing. Optimisation of antibacterial treatment should be viewed in the context of the need to determine plasma drug concentrations, pharmacoeconomic considerations and control of drug-related adverse events. Therapeutic proposals should be developed within the framework of the antibacterial policy of each hospital. The present review is focused on the description of the therapeutic strategies for the main infectious processes caused by Gram-positive cocci in severely ill patients admitted to the ICU according to a review of the pertinent literature and the clinical experience of the authors.