Factors influencing the implementation of antibiotic de-escalation and impact of this strategy in critically ill patients

• Published in: Critical care (London, England) Vol. 17; no. 4; p. R140
• Main Authors: Gonzalez, Leslie, Cravoisy, Aurélie, Barraud, Damien, Conrad, Marie, Nace, Lionel, Lemarié, Jérémie, Bollaert, Pierre-Edouard, Gibot, Sébastien
• Format: Journal Article
• Language: English
• Published: England BioMed Central Ltd 12.07.2013; BioMed Central
• Subjects: Aged; Anti-Bacterial Agents - administration & dosage; Anti-Bacterial Agents - therapeutic use; Antibiotics; Bacterial Infections - prevention & control; Care and treatment; Critical Care - methods; Critical care medicine; Dosage and administration; Drug Administration Schedule; Drug resistance in microorganisms; Female; Health aspects; Humans; Male; Medical research; Medicine, Experimental; Middle Aged; Retrospective Studies; Shock, Septic - drug therapy; Treatment Outcome; Withholding Treatment
• ISSN: 1364-8535; 1466-609X
• DOI: 10.1186/cc12819

A rational use of antibiotics is of paramount importance in order to prevent the emergence of multidrug resistant bacteria that can lead to therapeutic impasse, especially in intensive care units (ICUs). A de-escalation strategy is therefore naturally advocated as part of better antibiotics usage. However, the clinical impact of such a strategy has not been widely studied. We aimed to assess the feasibility and the clinical impact of a de-escalation strategy in a medical ICU and to identify factors associated when de-escalation was possible. We performed a retrospective study of patients hospitalized in a medical ICU over a period of six months. Independent factors associated with de-escalation and its clinical impact were assessed. Two hundred and twenty-nine patients were included in the study. Antibiotics were de-escalated in 117 patients (51%). The appropriateness of initial antibiotic therapy was the only independent factor associated with the performance of de-escalation (OR = 2.9, 95% CI, 1.5-5.7; P = 0.002). By contrast, inadequacy of initial antibiotic therapy (OR = 0.1, 0.0 to 0.1, P <0.001) and the presence of multidrug resistant bacteria (OR = 0.2, 0.1 to 0.7, P = 0.006) prevented from de-escalation. There were no differences in terms of short (ICU) or long-term (at 1 year) mortality rates or any secondary criteria such as ICU length of stay, duration of antibiotic therapy, mechanical ventilation, incidence of ICU-acquired infection, or multi-drug resistant bacteria emergence. De-escalation appears feasible in most cases without any obvious negative clinical impact in a medical ICU.