Background
De-escalation of empirical antimicrobial therapy, a key component of antibiotic stewardship, is considered difficult in ICUs with high rates of antimicrobial resistance.
Objectives
To assess the feasibility and the impact of antimicrobial de-escalation in ICUs with high rates of antimicrobial resistance.
Methods
Multicentre, prospective, observational study inseptic patients with documented infections. Patients in whom de-escalation was applied were compared with patients without de-escalation by the use of a propensity score matching by SOFA score on the day of de-escalation initiation.
Results
A total of 262 patients (mean age 62.2± 15.1 years) were included. Antibiotic-resistant pathogens comprised 62.9%, classified as MDR (12.5%), extensively drug-resistant (49%) and pandrug resistant (1.2%). In 97 (37%) patients de-escalation was judged not feasible in view of the antibiotic susceptibility results. Of the remaining 165 patients, judged as patients with de-escalation possibility, de-escalation was applied in 60 (22.9%). These were matched to an equal number of patients without de-escalation.
In this subset of 120 patients, de-escalation compared with no de-escalation was associated with lower all-cause 28 day mortality (13.3% versus 36.7%, OR 0.27, 95% CI 0.11–0.66, P=0.006); ICU and hospital mortality were also lower. De-escalation was associated with a subsequent collateral decrease in the SOFA score. Cox multivar- iate regression analysis revealed de-escalation as a significant factor for 28 day survival (HR 0.31, 95% CI 0.14–0.70, P = 0.005).
Conclusion
In ICUs with high levels of antimicrobial resistance, feasibility of antimicrobial de-escalation was limited because of the multi-resistant pathogens isolated. However, when de-escalation was feasible and applied, it was associated with lower mortality.
Source: Journal of Antimicrobial Chemotherapy, Volume 75, Issue 12, December 2020, Pages 3665–3674, https://doi.org/10.1093/jac/dkaa375
