Nosocomial sepsis: how to reconcile immediate broad-spectrum therapy with minimal ecological pressure and healthcare cost

In settings with a high prevalence of antimicrobial resistance, the empirical use of broad-spectrum antibiotics in sepsis is often necessary. However, in culture-negative sepsis, these agents are frequently continued to the full treatment duration, entailing potential collateral damage and a significant economic burden. In this context, clinical evidence suggests that failure to detect P. aeruginosa or MDR-Enterobacterales carries a high NPV for subsequent infection by these microorganisms. We propose an algorithm that ensures adequate empirical coverage while enabling antibiotic de-escalation in culture-negative cases based on colonization status.