Table 5.
Clinical presentation at day 7 of empiric therapy and outcome in patients with or without de-escalation
| De-escalation (n = 110) | No de-escalation (n = 96) | Escalation (n = 65) | No change (n = 31) | |
|---|---|---|---|---|
| Definitive anti-infective therapy | ||||
| Monotherapy, n (%) | 64 (58) | 21 (22) | 9 (14) | 12(29)a |
| Combination of two drugs, n (%) | 33 (30) | 39 (41) | 31 (48) | 8 (26)b |
| Combination of three drugs or more, n (%) | 13 (12) | 36 (38) | 25 (38) | 11 (35) |
| Use of carbapenems, n (%) | 5 (5) | 23 (24)a | 18 (28) | 5 (16) |
| Use of piperacillin-tazobactam, n (%) | 28 (25) | 39 (41)b | 19 (29) | 20 (65)a |
| Use of vancomycin, n (%) | 11 (10) | 41 (43)a | 33 (51) | 8 (26)b |
| Use of antifungals, n (%) | 29 (26) | 43 (45)a | 31 (48) | 12 (39) |
| Use of azoles, n (%) | 28 (25) | 39 (41)b | 28 (43) | 11 (35) |
| Use of echinocandins, n (%) | 1 (1) | 3 (3) | 3 (5) | – |
| Duration of anti-infective therapy, days, median (IQR) | 10 (10–14) | 10 (10–14) | 10 (10–14) | 10 (10–14) |
| Clinical changes between days 3 and 7 | ||||
| Number of cases at day 7 | 91 | 75 | 51 | 24 |
| Changes in SOFA scorec, median (IQR) | −1 (−3 to 0) | −2 (−4 to 0) | −2 (−4 to 0) | −2 (−4 to 0) |
| Decreased SOFA scorec, n (%) | 57 (63) | 48 (64) | 35 (54) | 13 (42) |
| Decreased temperaturec, n (%) | 38 (42) | 36 (48) | 27 (42) | 9 (29) |
| Decreased WBCc, n (%) | 31 (34) | 17 (23) | 12 (18) | 5 (16) |
| Clinical improvement at day 7c, n (%) | 16 (18) | 9 (12) | 9 (14) | – |
| Discharge between days 3 and 7, n (%) | 20 (22) | 15 (20) | 10 (20) | 5 (21) |
| Death between days 3 and 7, n (%) | 1 (1) | 3 (4) | 2 (4) | 1 (4) |
| Medical complications | 12 (12) | 14 (16) | 6 (10) | 8 (29) |
| Surgical complications | 26 (25) | 21 (24) | 10 (17) | 11 (39)b |
| Reoperation, n (%) | 38 (35) | 35 (36) | 19 (29) | 16 (51)b |
| Time to reoperation, days, median (IQR) | 6 (5–9) | 6 (5–8) | 5 (4–8) | 7 (6–10) |
| Superinfection on subsequent reoperationd, n (%) | 23 (61) | 23 (66) | 13 (68) | 10 (63) |
| Emergence of MDR strainsd, n (%) | 21 (55) | 20 (57) | 11 (58) | 9 (56) |
| Emergence of ESBL Enterobacteriaceae d, n (%) | 5 (13) | 5 (14) | 3 (16) | 2 (13) |
| Emergence of MDR NFGNBd, n (%) | 9 (24) | 5 (14) | 2 (11) | 3 (19) |
| Emergence of MRSAd, n (%) | 9 (24) | 8 (23) | 6 (32) | 2 (13) |
| Duration of mechanical ventilatione, days, median (IQR) | 7 (3–13) | 7 (3–11) | 7 (2–10) | 7 (3–15) |
| ICU length of staye, days, median (IQR) | 12 (8–20) | 12 (8–21) | 12 (8–21) | 14 (5–23) |
| Survival at day 28, n (%) | 91 (83) | 72 (75) | 51 (78) | 21 (68) |
| ICU mortality rate, n (%) | 23 (21) | 32 (33)b | 18 (28) | 14 (45) |
| Hospital mortality rate, n (%) | 25 (23) | 33 (34) | 19 (29) | 14 (45) |
ESBL extended-spectrum β-lactamase, ICU intensive care unit, IQR interquartile range, MDR multidrug-resistant, MRSA methicillin-resistant Staphylococcus aureus, NFGNB nonfermenting Gram-negative bacilli, SOFA Sequential Organ Failure Assessment, WBC white blood cell count
Among those without de-escalation, the results were analyzed in terms of subsequent antibiotic escalation or no change
a p < 0.01 versus escalation therapy
b p < 0.05 versus escalation therapy
cResults expressed as number of patients at day 7 in the same group
dResults expressed as number of patients who underwent reoperation in the same group
eResults calculated for ICU survivor patients