The use of extracorporeal membrane oxygenation (ECMO) in the management of patients with severe respiratory and/or cardiac failure, has increased in recent years with infectious etiologies being a frequent presentation or secondary complication of ECMO support [1].

Antimicrobials are frequently administered to patients supported by ECMO to treat a primary bacterial pneumonia or a nosocomial infection [1,2]. Therefore, appropriate selection and timely administration of antimicrobials is paramount to successful treatment of infections and improved patient outcomes. Strategies that optimize dosing of antimicrobials centered on pharmacokinetic (PK) and pharmacodynamic (PD) principles are recommended by international guidelines [3]. However, achieving optimal antimicrobial exposure in critically ill patients receiving ECMO can be challenging due to significant PK/PD perturbations from critical illness (i.e., altered kidney function, fluid overload, body habitus) and the ECMO circuit [4,5].

Extracorporeal membrane oxygenation circuit components including the membrane oxygenator and polyvinyl chloride tubing as well as a drug's physicochemical properties may contribute to drug sequestration at initiation and throughout the ECMO duration [6]. Lipophilic (log p 2.0 or more) and highly protein bound (>80–90%) drugs have a greater propensity to be sequestered within the ECMO circuit [7]. Alternatively, hydrophilic drugs may be susceptible to lower plasma concentrations at the initiation of ECMO as a result of increased volume of distribution (Vd). The use of standard dosing recommendations derived from healthy individuals may not achieve desired PK/PD targets in this patient population and result in treatment failure and microbiological resistance, whereas empiric aggressive dosing may lead to toxicities [8,9].

A survey was conducted to characterize dosing strategies of common antimicrobials used for critically ill adult patients receiving ECMO and whether they differ from critically ill adults not supported with ECMO. Additionally, we sought to make comparisons between higher and lower volume ECMO centers given that there may be an association between ECMO volume and practice patterns.