Should the Clinical Pharmacologist Play a Role in the Multidisciplinary Team Managing Severe Necrotizing Soft-Tissue Infections?

Abstract

Necrotizing soft-tissue infections (NSTIs) are uncommon severe bacterial infections characterized by a high morbidity and mortality rate, frequently requiring intensive care unit (ICU) admission because of the occurrence of septic shock and multiorgan failure [1]. Recently, several viewpoints focused on the challenges concerning the treatment of critically ill patients affected by severe NSTIs, specifically highlighting the key role of multidisciplinary assessment and management [2–4]. It has been suggested that the implementation of a synchronized multidisciplinary team, coordinated by the intensivist and including the surgeon, the infectious disease specialist, the clinical microbiologist, and the dermatologist, may become a cornerstone in the management of critical patients with NSTIs. In this regard, a multidisciplinary taskforce coupled with implementation of a specific bundle has proven to improve the outcome of severe NSTIs, leading to faster improvement of end-organ damage and a decrease in the mortality rate [5, 6]. Should the clinical pharmacologist play a role in this multidisciplinary team? In the last update of the Surviving Sepsis Campaign [7], it is recommended that the dosing schedule of antimicrobials should be optimized according to accepted pharmacokinetic/pharmacodynamic (PK/PD) principles and specific drug properties in patients with sepsis or septic shock. Consistently, given the remarkable clinical complexity of critically ill patients affected by severe NSTIs, the clinical pharmacologist could provide aid in selecting the best-tailored dosing schedule of administered antimicrobials, by implementing PK/PD concepts and an adaptive therapeutic drug monitoring (TDM) approach. Why are PK/PD concepts and an adaptive TDM strategy so fundamental in this setting? We may identify four major determinants (Fig. 1):