Table 5.
Summary of studies on antibiotic deescalation.
| Study type | Setting | Patients | Deescalation rate | Association with outcomes | Factors associated with no deescalation | |
|---|---|---|---|---|---|---|
| Rello et al., 2004 [2] | Prospective, observational | Medical-surgical ICU with VAP | 115 | 31.4% | Not reported | Nonfermenting Gram-negative bacillus (2.7% versus 49.3%), late-onset pneumonia (12.5% versus 40.7%), p < 0.05 |
|
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| Eachempati et al., 2009 [3] |
Observational | Surgical ICU with VAP | 138 | 55% | No difference in recurrent pneumonia rate or mortality, 34% versus 42% | Not reported |
|
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| De Waele et al., 2010 [4] | Retrospective | Surgical ICU | 113 | 42% | No difference in mortality rate (7% versus 21%, p 0.12) | Negative cultures, colonization with multiresistant Gram-negative organisms |
|
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| Hibbard et al., 2010 [5] | Retrospective | Surgical ICU, VAP | 811 antibiotic days | 78%–59% | No change in resistance rates | Not reported |
|
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| Morel et al., 2010 [6] | Retrospective | Mixed ICU | 116 | 45% | Recurrent infection (19% versus 5%, p 0.01) | Inadequate empiric antibiotic and initial therapy not containing aminoglycoside |
|
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| Gonzalez et al., 2013 [7] | Retrospective | Medical ICU | 229 | 51% | No differences in mortality, length of stay, antibiotic duration, mechanical ventilation, ICU-acquired infection, or drug-resistant bacteria | Inadequacy of initial antibiotic therapy (OR = 0.1, 0.0 to 0.1, p < 0.001), multidrug resistant bacteria (OR = 0.2, 0.1 to 0.7, p = 0.006) |
|
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| Duchêne et al., 2013 [8] | Retrospective | Urosepsis | 80 | 46% | Not reported | Shock, renal abscess, obstructive uropathy, bacterial resistance |
|
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| Garnacho-Montero et al., 2014 [9] | Prospective, observational | Medical | 712 | 34.9% | Deescalation protective for mortality (OR 0.54; 95% CI 0.33-0.89) | Not reported |
|
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| Carugati et al., 2015 [10] | Secondary analysis of CAP database | Medical with CAP | 261 | 63.2% | No association with mortality | More severe presentation |
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| Lee et al., 2015 [11] | Retrospective | Community-onset monomicrobial Enterobacteriaceae (CoME) bacteremia | 189 | 45.5% | Deescalation strategy was protective for mortality (OR 0.37, p 0.04) | Not reported |
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| Madaras-Kelly et al., 2016 [12] | Retrospective | HCAP in VA system | 9319 | 28.3% | Not reported | Deescalation associated with initial broad-spectrum therapy (OR 1.5, 95% CI 1.4–1.5), collection of respiratory tract cultures (OR 1.1, 95% CI 1.0–1.2), care in higher complexity facilities (OR 1.3, 95% CI 1.1–1.6) |
|
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| Falguera et al., 2010 [13] | RCT | Community-acquired pneumonia | 177, deescalation by urinary antigen results | — | Higher cost (p 0.28), reduced adverse events (9% versus 18%, p 0.12), lower exposure to broad-spectrum antimicrobials (154.4 versus 183.3 daily doses per 100 patient days) | |
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| Kim et al., 2012 [14] | RCT | Medical ICU, hospital-acquired pneumonia | 109 | — | No differences in ICU stay or mortality rates, higher risk of MRSA with deescalation; HR 3.84; 95% CI 1.06–13.91 | |
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| Leone et al., 2014 [15] | Multicenter, RCT | Severe sepsis | 60 | — | Deescalation resulted in prolonged duration of ICU stay; mean difference 3.4 (95% CI −1.7–8.5); no effect on mortality | Not reported |
ICU: intensive care unit; VAP: ventilator-associated pneumonia; CAP: community-acquired pneumonia; HCAP: healthcare associated pneumonia; HR: hazard ratio; OR: odds ratio.