Navigating antimicrobial stewardship in critical intracerebral hemorrhage complicated by severe pneumonia: A case report of antibiotic escalation strategy and clinical recovery

Cerebral haemorrhage is a leading cause of mortality, frequently complicated by intensive care unit (ICU)-acquired infections such as pneumonia and sepsis. Managing these infections poses a significant challenge, requiring a delicate balance between rapid infection control and strict adherence to antimicrobial stewardship programmes. We report the case of a 49-year-old female presenting with a decreased level of consciousness, right-sided motor weakness, and severe hypertension. Diagnostic imaging confirmed a 36.5 mL acute left temporoparietal cerebral haemorrhage. Concurrently, she was diagnosed with severe pneumonia and sepsis based on clinical and radiological criteria. Following an urgent craniotomy, the patient required mechanical ventilation in the ICU. Empirical antibiotic therapy was initiated with ampicillin-sulbactam, adhering to stratification I of the local antimicrobial resistance control programme. However, persistent leucocytosis and an inability to wean from mechanical ventilation by day three necessitated a protocol-guided escalation to a stratification III regimen, comprising intravenous meropenem and levofloxacin, driven by clinical deterioration in the absence of initial causative microbiological data. Following this structured escalation, the patient exhibited marked clinical and neurological improvement. She was successfully extubated on day six and transferred to the general ward by day seven. This case demonstrates that whilst the routine use of prophylactic antibiotics in cerebral haemorrhage remains controversial, the implementation of a prompt, clinically-responsive and protocol-driven antibiotic escalation strategy is vital for resolving severe nosocomial infections and optimising clinical outcomes, without undermining global antimicrobial stewardship effort.