β-lactam infusion strategies in critical illness: is continuous superior to extended infusion? A systematic review and network meta-analysis.

Background: Prolonged β-lactam infusion is common in critical care, but whether continuous infusion (CI) improves outcomes more than extended infusion (EI) is unclear. Methods: We conducted a systematic review and random-effects Bayesian network meta-analysis of randomized controlled trials in critically ill adults comparing intravenous β-lactam administration by continuous infusion (24-hour infusion), extended infusion (≥3 h per dose), and intermittent infusion (≤1 h per dose). We searched PubMed, EMBASE, Web of Science, and the Cochrane Library from January 1, 2000, to July 25, 2025. Two reviewers independently screened records, extracted data, and assessed risk of bias. Relative risks (RRs) and mean differences (MDs) were synthesized using random-effects models. Network meta-analysis used Markov chain Monte Carlo methods in R, with complementary pairwise analyses in Stata. Certainty of evidence was assessed using GRADE for network meta-analysis. Results: Twenty-five randomized trials ( Conclusions: CI did not demonstrate greater clinical benefit than EI. CI can reduce patient mortality, and both CI and EI appear to improve clinical cure rates compared with II. CI conferred no additional benefit over EI, suggesting that EI may be sufficient as a prolonged-infusion strategy in clinical practice. However, this finding is based on indirect evidence. The apparent advantage of EI should therefore be regarded as hypothesis-generating and requires confirmation in adequately powered head-to-head randomized controlled trials. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/view/CRD42023452814, PROSPERO CRD42023452814.