Clinical outcomes of carbapenem de-escalation regardless of microbiological results: A propensity score analysis

Abstract

Objective: The aim of this study was to evaluate the safety and efficacy of de-escalation in patients under treatment with carbapenems and its impact on clinical outcomes. Methods: A prospective observational study was conducted for 1 year. Patients administered active carbapenems for at least 24 h were included. Primary outcomes were in-hospital mortality, mortality at 30 days after carbapenem prescription, and infection-related readmission within 30 days. De-escalation was defined as the substitution of carbapenem with narrower spectrum antimicrobial agents or its discontinuation during the first 96 h of treatment. Results: The study included 1161 patients, and de-escalation was performed in 667 (57.5%) of these. In the de-escalation group, 54.9% of cultures were positive. After propensity score matching, 30-day mortality was lower (17.4% vs. 25.7%, p = 0.036), carbapenem treatment was 4 days shorter (4 vs. 8 days, p < 0.001), total antibiotic therapy duration was 2 days longer (12 vs. 10 days, p = 0.003), and length of hospital stay was 5 days shorter (8 vs. 13 days, p = 0.008) in the de-escalated versus non-de-escalated patients. Inhospital mortality and 30-day readmission rates did not differ significantly between these groups. Conclusion: Carbapenem de-escalation is a safe strategy that does not compromise the clinical status of patients.

Impact of antimicrobial de-escalation on mortality: a literature review of study methodology and recommendations for observational studies

“…For 33 studies solely reporting crude estimates on mortality, we confine ourselves by stating that they suffer from severe confounding by indication and are of no use for a causal inference. For the remaining we discuss studies that adjusted for potential confounders (N = 19) [15,20,21,27,28,31,33,34,40,43,[45][46][47]50,53,56,57,60,61]. For the purpose of this review, we focus on three main issues: (1) lack of adjustment for the patients' clinical course, (2) modeling deescalation as a fixed variable, and (3) modeling time-varying confounders as fixed variables.…”

Antimicrobial de-escalation as part of antimicrobial stewardship in intensive care: no simple answers to simple questions—a viewpoint of experts

“…First, although none of the involved studies was designed to assess its effect on total duration of therapy, ADE has been associated with an increase in the total duration of antimicrobial therapy [1]. There may be multiple possible explanations for this finding, including potential "errors in counting total days of therapy" and the perception that narrow-spectrum antimicrobials are harmless and can be continued for longer periods of time [12]. Second, the risk of using ADE as an excuse to continue antimicrobials in the absence of infection is likely to cause more harm than stopping all antimicrobials alltogether.…”

Discontinuation of Glycopeptides in Patients with Culture Negative Severe Sepsis or Septic Shock: A Propensity-Matched Retrospective Cohort Study

“…Another study even demonstrated improved survival in patients who received antimicrobial DE therapy [5]. However, only a few studies deal with the impact of DE therapy in relation to specific pathogens or specific antibiotics [6].…”