De-escalating Antibiotic Use in the Inpatient Setting: Strategies, Controversies, and Challenges

Abstract

A consensus definition of ADE remains elusive at this time. Preliminary studies utilizing rapid diagnostic tests including matrix-assisted laser desorption/ionization time of flight (MALDI-TOF), procalcitonin, and other molecular techniques have demonstrated the potential to support ADE strategies. In the absence of evidence-based, highly specific ADE protocols, the likelihood that individual providers will make consistent, often challenging, decisions to de-escalate antibiotic therapy is low. Antimicrobial stewardship programs should support local physicians with ADE and develop innovative ways to integrate ADE into the broader construct of antimicrobial stewardship programs. The evolving field of rapid diagnostics has significant potential to improve ADE strategies, but more research is needed to fully realize this goal.

Risk Factors Affecting Clinical Outcome in Patients with Carbapenem-Resistant K. pneumoniae: A Retrospective Study

“…This phenomenon was probably caused by the very high MIC of carbapenems (>16 μg/ml) against CRKP. This result supports the importance of choosing the right antibacterials in light of drug sensitivity results and promptly implementing antibiotic de-escalation to avoid similar incidents [ 37 ]. Moreover, medical invasive devices, such as an indwelling gastric tube, greatly increase the chance of bacterial infection [ 38 ], which to some extent increases the difficulty of treatment and negatively affects the clinical outcome of patients with CRKP.…”

Enhanced antimicrobial de-escalation for pneumonia in mechanically ventilated patients: a cross-over study

“…However, as emphasized in several recent systematic reviews, antibiotic de-escalation is dependent on multiple factors, such as risk for infection with resistant pathogens, severity of illness, clinical response to initial therapy, site of infection, microorganisms associated with infection, adequacy of source control, and institutional practice patterns [10, 15]. Moreover, antibiotic de-escalation is accepted as a part of the global antimicrobial stewardship approach, inclusive of other elements such as the route and mode of antibiotic administration and the total duration of antimicrobial therapy [15].…”

“…This creates a situation that often promotes the empiric administration of broad-spectrum antibiotics. The advent of rapid diagnostics is likely to facilitate the implementation of EAD in the future with the more timely availability of pathogen identification and antibiotic susceptibility compared to current approaches [10, 16]. …”

“…Further research must be done to determine what defines antimicrobial de-escalation, when it is appropriate, how to integrate infectious disease consultation into the ICU, when to “re-escalate” therapy, and how to transition antimicrobial decision-making when patients move from the ICU to the hospital ward [10, 17]. At present there are no established guidelines or benchmarks for de-escalation practices in critically ill patients that could serve as a reference point for ICU clinicians.…”

“…The practice of antibiotic de-escalation has emerged as an antibiotic decision-making strategy in the ICU balancing the need for IAAT, in order to improve patient outcomes, with the need for avoidance of unnecessary antibiotics so as to reduce resistance emergence [10]. De-escalation generally refers to tailoring of empirical antibiotic treatment according to the susceptibilities of the bacteria isolated, selecting the narrowest spectrum antibiotic or stopping antibiotics altogether if non-infectious etiology is established.…”