De-escalation as part of a global strategy of empiric antibiotherapy management. A retrospective study in a medico-surgical intensive care unit

Abstract

IntroductionMost data on de-escalation of empirical antimicrobial therapy has focused on ventilator-associated pneumonia. In this retrospective monocentric study, we evaluated de-escalation as part of a global strategy of empiric antibiotherapy management irrespective of the location and the severity of the infection. The goal of this trial was to assess the application of a de-escalation strategy and the impact in terms of re-escalation, recurrent infection and to identify variables associated with de-escalation.MethodsAll consecutive patients treated with empiric antibiotic therapy and hospitalized in the intensive care unit for at least 72 hours within a period of 16 months were included. We compared the characteristics and outcome of patients who have experienced de-escalation therapy with those who have not.ResultsA total of 116 patients were studied corresponding to 133 infections. Antibiotic therapy was de-escalated in 60 cases (45%). De-escalation, primarily accomplished by a reduction in the number of antibiotics used, was observed in 52% of severe sepsis or septic shock patients. Adequate empiric antibiotic and use of aminoglycoside were independently linked with de-escalation. De-escalation therapy was associated with a significant reduction of recurrent infection (19% vs 5% P = 0.01). Mortality was not changed by de-escalation.ConclusionsAs part of a global management of empiric antibiotherapy in an intensive care unit, de-escalation might be safe and feasible in a large proportion of patients.

Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016

“…Early de-escalation of antimicrobial therapy in the context of combination therapy as described here has not been studied. However, observational studies have shown that early de-escalation of multidrug therapy is associated with equivalent or superior clinical outcomes in sepsis and septic shock [54,[190][191][192]; despite this, at least one study has indicated an increased frequency of superinfection and longer ICU stay [192].…”

Evaluation of the Benefits of De-Escalation for Patients with Sepsis in the Emergency Intensive Care Unit

“…In this study, de-escalation was defined as a change to more narrow-spectrum antibiotics or a reduction in the types of antibiotics used after identification of the causative pathogen and its drug sensitivity. Criteria for de-escalation followed those reported by Kollef et al (9). Evaluation of the utility of de-escalation was conducted by dividing the subjects into two groups based on de-escalation and comparing and assessing the mortality rate, length of hospital stay (days), and length of antibiotic administration (days) between the two groups.…”

“…The antimicrobial de-escalation is definded as change to a narrow spectrum antibacterial drug or reduce the type of antimicrobial drug (7). The successful use of antibiotics in de-escalation has indicated that such use does not increase the recurrence or mortality rates for sepsis (8,9), which results in improvements in survival rates and length of hospital stay in cases of ventilator-associated pneumonia (7). Further, deescalation has also been reported as a safe strategy even for patients with severe sepsis and septic shock admitted to the intensive care unit (ICU) (10).…”

European guidelines for empirical antibacterial therapy for febrile neutropenic patients in the era of growing resistance: summary of the 2011 4th European Conference on Infections in Leukemia

“…[84][85][86] There are very few data on de-escalation strategies in neutropenic patients after identification of a clinically relevant pathogen, but no data on de-escalation when no pathogen has been identified. 87 …”