**1. Introduction**

In this chapter, we will focus on the critically ill patients with Gram-negative **pneumonia**, the prevalence of multidrug resistance, factors associated with patients developing these resistance infections. Surveillance, infection control, and early detection by means of utilizing rapid diagnostics and other methodologies are important for early prevention of disease. The reader will be able to understand how and why the administration of early appropriate empiric antibiotics is

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

key for survival in the critically ill. We will emphasize on the importance of robust antimicrobial stewardship programs, which are in accordance with Centers for Disease Control and Prevention (CDC) core elements. New regulatory mandates from the Joint Commission (TJC) on antimicrobial stewardship programs will require hospitals to be compliant for accreditation. Finally, we will end the chapter with an outlook on future antibiotics in Phase III development to aid in the combat against multidrug-resistant (MDR) organisms.

**3. Prevalence of MDROs and risk factors in the critically ill**

tively. These serious infections contribute to roughly 600 deaths each year [5].

categories: urgent, serious, and concerning (**Table 1**).

**Urgent threats** *Clostridium difficile*

**Serious threats**

Drug-resistant *Shigella*

2013 [5].

Drug-resistant tuberculosis\* **Concerning threats**

Carbapenem-resistant *Enterobacteriaceae* (CRE)

Drug-resistant *Neisseria gonorrhoeae*

Multidrug-resistant *Acinetobacter*\* Drug-resistant *Campylobacter*

Fluconazole-resistant *Candida* (a fungus)

Vancomycin-resistant *Enterococcus* (VRE) Multidrug-resistant *Pseudomonas aeruginosa*\* Drug-resistant nontyphoidal *Salmonella* Drug-resistant *Salmonella* Typhi

Drug-resistant *Streptococcus pneumoniae*\*

Methicillin-resistant *Staphylococcus aureus* (MRSA)\*

Vancomycin-resistant *Staphylococcus aureus* (VRSA) Erythromycin-resistant Group A *Streptococcus* Clindamycin-resistant Group B *Streptococcus*

**Table 1.** CDC antibiotic resistance threats in the United States, 2013.

Extended spectrum β-lactamase producing *Enterobacteriaceae* (ESBLs)\*

The CDC in 2013 published *Antibiotic Resistance Threats in the United States*. Regarding the level of concern, CDC has, for the first time, prioritized bacteria in this report into one of three

Multidrug-Resistant Gram-Negative Pneumonia and Infection in Intensive Care Unit

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The CDC has placed carbapenem-resistant *Enterobacteriaceae* (CRE) as an urgent threat level. CRE confers resistance to last-line antibiotics such as carbapenems, by producing a β-lactamase enzyme called KPC (*K. pneumoniae* carbapenemase-producing). The CDC reports their laboratories have confirmed CRE in 44 states within healthcare facilities across the United States. CRE causes more than 9000 healthcare-associated infections (HAI) annually, among these the two most common types are carbapenem-resistant *Klebsiella* and carbapenem-resistant *E. coli*. The percentages of the United States CRE healthcare-associated infections for *Klebsiella* spp. and carbapenem-resistant *Escherichia coli* are 11 and 2%, respec-

*Notes*: \*MDROs associated with pneumonia. Reproduced from CDC. Antibiotic resistance threats in the United States,
