Impact of de-escalation therapy on clinical outcomes for intensive care unit-acquired pneumonia

Abstract

IntroductionDe-escalation therapy is a strategy currently used for the management of nosocomial pneumonia. In this study, we evaluated clinical outcomes and risk factors related to de-escalation therapy in patients with intensive care unit (ICU)-acquired pneumonia.MethodsThis was a retrospective observational cohort study of ICU patients who developed pneumonia more than 48 hours after admission to the ICU at Samsung Medical Center from September 2004 to December 2007.ResultsThe 137 patients comprised 44 (32.1%) who received de-escalation therapy and 93 in the non-de-escalation group. The de-escalation group showed a lower pneumonia-related mortality rate than the non-de-escalation group by day 14 (2.3% vs. 10.8%, respectively; P = 0.08) and by day 30 (2.3% vs. 14%, respectively; P = 0.03) after the diagnosis of pneumonia. The variables independently associated with ICU-acquired pneumonia-related mortality included the Acute Physiology and Chronic Health Evaluation II (APACHE II) score and the modified Clinical Pulmonary Infection Score (CPIS) after 5 days with pneumonia. The non-de-escalation group had significantly higher APACHE II score and modified CPIS after 5 days with ICU-acquired pneumonia compared to the de-escalation group. Among all patients, 20.4% (28 of 137) had negative cultures for pathogens, and 42.9% (12 of 28) received de-escalation therapy. The latter 12 patients received de-escalation therapy and survived 30 days after the diagnosis of pneumonia.ConclusionsPatients in the de-escalation group showed a significantly lower mortality rate compared to patients in the non-de-escalation group. De-escalation therapy can be safely provided to patients with ICU-acquired pneumonia if they are clinically stable by day 5, even in those whose respiratory specimen cultures yield no specific pathogens.

Antibiotic De-escalation Therapy in Neurosurgical Patients with Ventilator-Associated Pneumonia in Intensive Care Unit: A Retrospective Observational Study

“…This figure is lower than 25% to 35% found in the previous studies involving medical, surgical and trauma patients with VAP. 10,12,21 The de-escalation rate was lower in our study compared to previous reports probably due to the types of patients included, as our study only included neurosurgical patients. Another factor that might influence the lower de-escalation rate in our study was the high proportion of unidentified organisms (culture-negative) from culture and sensitivity results.…”

A Trial of Discontinuation of Empiric Vancomycin Therapy in Patients with Suspected Methicillin-Resistant Staphylococcus aureus Health Care-Associated Pneumonia

“…Our study differs from several earlier reports dealing with deescalation of antibiotics in hospitalized patients with pneumonia (3,(35)(36)(37)(38). Our study included patients with no respiratory cultures obtained or with sputum cultures classified as inadequate by the laboratory; patients with good-quality sputum specimens that yielded either respiratory pathogens or only normal oral flora were excluded.…”

“…Our study included patients with no respiratory cultures obtained or with sputum cultures classified as inadequate by the laboratory; patients with good-quality sputum specimens that yielded either respiratory pathogens or only normal oral flora were excluded. In contrast, in several previous studies that required pneumonia patients to have respiratory and/or blood cultures performed, de-escalation was performed on 30 to 75% of patients who were classified as culture negative, which was defined as no respiratory pathogen recovered from cultures (35,36,38). However, Labelle et al included 290 pneumonia patients for whom no respiratory culture was obtained plus 149 patients whose respiratory cultures yielded no growth or normal oral flora (the two groups combined were classified as culture negative) (3).…”

Ventilator-associated pneumonia: present understanding and ongoing debates

“…In one study of 137 patients with ICU-acquired pneumonia, de-escalation was done in 32 %, and these patients had a lower pneumoniarelated mortality than those without de-escalation [51]. However, de-escalation may not have been the reason for a better outcome, but simply a marker of a responding patient, since those with de-escalation had a lower APACHE II and CPIS score at day 5 than those who did not.…”