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De-Escalation i..

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De-escalation strategies are recommended in infections of hospital-acquired nature where there is a wide variety of causative microorganisms and high risk for resistance. Multiple studies have examined antibiotic de-escalation particularly in patients with hospital-acquired pneumonia.1,2,3,4 However, risk of recurrent infection when using such de-escalation strategy remains a concern among healthcare professionals.2,5

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A recently published study in Crit Care Med reviewed the use of antibiotic de-escalation in patients with severe sepsis with an aim of assessing how de-escalation therapy is applied in this patient population and the impact on patient outcomes. One hundred sixty-nine patients with 216 episodes of severe sepsis due to a nosocomial-acquired infection, who required broad-spectrum β-lactam antibiotics alone or in combination with other antimicrobial agents, and were admitted to a 35-bed medical-surgical intensive care unit over a one year period were included. Appropriateness of antimicrobial therapy was determined according to whether or not it had in vitroactivity against the causative microorganism.6

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According to the therapeutic strategy in the 5 days after the start of antimicrobial therapy, patients were classified into four groups: de-escalation (interruption of an antimicrobial agent or change of antibiotic to one with a narrower spectrum); (no change in antibiotic therapy); escalation (addition of a new antimicrobial agent or change in antibiotic to one with a broader spectrum); and mixed changes. All antibiotic strategies are reviewed by infectious disease specialists three times per week.

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The authors showed that de-escalation was applied in 93 episodes (43%), escalation was applied in 22 episodes (10%), mixed changes were applied in 24 (11%) episodes, and there was no change in empirical antibiotic therapy in 77 (36%) episodes. In these 77 episodes, antimicrobial therapy was not changed due to the sensitivity pattern of causative organisms and previous antibiotic therapy. 

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This study demonstrates that de-escalation therapy is possible in this patient population and can ensure adequate coverage of causative organisms with limited risks for the development of multi-resistant bacteria.

1. Alvarez-Lerma F, Alvarez B, Luque P, et al. Empiric broad-spectrum antibiotic therapy of nosocomial pneumonia in the intensive care unit: A prospective observational study. Crit Care 2006;10:R78.   [PubMed: 16704742]
2. Eachempati SR, Hydo LJ, Shou J, et al. Does de-escalation of antibiotic therapy for ventilator-associated pneumonia affect the likelihood of recurrent pneumonia or mortality in critically ill surgical patients? J Trauma 2009;66:1343–1348.   [PubMed: 19430237]
3. Amsden GW, Ballow CH, Bertino JS. Pharmacokinetics and Pharmacodynamics of Anti-infective Agents. In: Principles and Practice of Infectious Diseases. Fifth Edition. Mandell GL, Bennett JE, Dolin R (Eds). Philadelphia, Churchill Livingstone, 2000, pp 253–261.
4. Hyatt JM, McKinnon PS, Zimmer GS, et al. The importance of pharmacokinetic/pharmacodynamic surrogate markers to outcomes. Focus on antibacterial agents. Clin Pharmacokinet 1995;28:143–160.   [PubMed: 7736689]
5. Morel J, Casoetto J, Jospe R, et al. Deescalation as part of a global strategy of empiric antibiotherapy management. A retrospective study in a ...

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