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
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
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.
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.
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
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
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
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 ...