Medical decision-making about antibiotic use in critically ill patients is challenging and complex. The need for antibiotic stewardship requires judicious prescription and choice of antimicrobials, as the need for effective therapy has to be put in balance with the need to limit undue selection pressure, and all this must be done in a context of diagnostic and prognostic uncertainty. This decision-making is not a single or static decision, but should rather be seen as an evolving series of successive decisions and choices that have to be made when the clinical case gradually unfurls its course while more diagnostic results progressively become available. As a means to clarify this decision process and stimulate the application of antibiotic stewardship in its different stages, it may be helpful to use a metaphor.

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