De-escalation as part of a global strategy of empiric antibiotherapy management. A retrospective study in a medico-surgical intensive care unit.
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ABSTRACT: Introduction
Most data on de-escalation of empirical antimicrobial therapy has focused on ventilator-associated pneumonia. In this retrospective monocentric study, we evaluated de-escalation as part of a global strategy of empiric antibiotherapy management irrespective of the location and the severity of the infection. The goal of this trial was to assess the application of a de-escalation strategy and the impact in terms of re-escalation, recurrent infection and to identify variables associated with de-escalation.Methods
All consecutive patients treated with empiric antibiotic therapy and hospitalized in the intensive care unit for at least 72 hours within a period of 16 months were included. We compared the characteristics and outcome of patients who have experienced de-escalation therapy with those who have not.Results
A total of 116 patients were studied corresponding to 133 infections. Antibiotic therapy was de-escalated in 60 cases (45%). De-escalation, primarily accomplished by a reduction in the number of antibiotics used, was observed in 52% of severe sepsis or septic shock patients. Adequate empiric antibiotic and use of aminoglycoside were independently linked with de-escalation. De-escalation therapy was associated with a significant reduction of recurrent infection (19% vs 5% P = 0.01). Mortality was not changed by de-escalation.Conclusions
As part of a global management of empiric antibiotherapy in an intensive care unit, de-escalation might be safe and feasible in a large proportion of patients.
SUBMITTER: Morel J
PROVIDER: S-EPMC3219998 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:ObjectivesConcern for late detection of bacterial pathogens is a barrier to early de-escalation efforts. The purpose of this study was to assess blood, respiratory and urine culture results at 72 h to test the hypothesis that early negative culture results have a clinically meaningful negative predictive value.MethodsWe retrospectively reviewed all patients admitted to the medical intensive care unit between March 2012 and July 2018 with blood cultures obtained. Blood, respiratory and urine culture results were assessed for time to positivity, defined as the time between culture collection and preliminary species identification. The primary outcome was the negative predictive value of negative blood culture results at 72 h. Secondary outcomes included sensitivity, specificity, positive predictive value and negative predictive value of blood, respiratory and urine culture results.ResultsThe analysis included 1567 blood, 514 respiratory and 1059 urine cultures. Of the blood, respiratory and urine cultures ultimately positive, 90.3%, 76.2% and 90.4% were positive at 72 h. The negative predictive value of negative 72-h blood, respiratory and urine cultures were 0.99, 0.82 and 0.97, respectively. Antibiotic de-escalation had good specificity, positive predictive value and negative predictive value for finalized negative cultures.ConclusionNegative blood and urine culture results at 72 h had a high negative predictive value. These findings have important ramifications for antimicrobial stewardship efforts and support protocolized re-evaluation of empiric antibiotic therapy at 72 h. Caution should be used in patients with clinically suspected pneumonia, since negative respiratory culture results at 72 h were weakly predictive of finalized negative cultures.
| S-EPMC8381457 | biostudies-literature
Project description:BackgroundEmpiric Gram-negative antibiotics are frequently changed in response to new information. To inform antibiotic stewardship, we sought to identify predictors of antibiotic changes using information knowable before microbiological test results.MethodsWe performed a retrospective cohort study. Survival-time models were used to evaluate clinical factors associated with antibiotic escalation and de-escalation (defined as an increase or decrease, respectively, in the spectrum or number of Gram-negative antibiotics within 5 days of initiation). Spectrum was categorized as narrow, broad, extended or protected. Tjur's D statistic was used to estimate the discriminatory power of groups of variables.ResultsIn 2019, 2 751 969 patients received empiric Gram-negative antibiotics at 920 study hospitals. Antibiotic escalation occurred in 6.5%, and 49.2% underwent de-escalation; 8.8% were changed to an equivalent regimen. Escalation was more likely when empiric antibiotics were narrow-spectrum (HR 19.0 relative to protected; 95% CI: 17.9-20.1), broad-spectrum (HR 10.3; 95% CI: 9.78-10.9) or extended-spectrum (HR 3.49; 95% CI: 3.30-3.69). Patients with sepsis present on admission (HR 1.94; 95% CI: 1.91-1.96) and urinary tract infection present on admission (HR 1.36; 95% CI: 1.35-1.38) were more likely to undergo antibiotic escalation than patients without these syndromes. De-escalation was more likely with combination therapy (HR 2.62 per additional agent; 95% CI: 2.61-2.63) or narrow-spectrum empiric antibiotics (HR 1.67 relative to protected; 95% CI: 1.65-1.69). Choice of empiric regimen accounted for 51% and 74% of the explained variation in antibiotic escalation and de-escalation, respectively.ConclusionsEmpiric Gram-negative antibiotics are frequently de-escalated early in hospitalization, whereas escalation is infrequent. Changes are primarily driven by choice of empiric therapy and presence of infectious syndromes.
| S-EPMC10182731 | biostudies-literature
Project description:PurposeThis study aimed to investigate the prevalence of antimicrobial de-escalation (ADE) strategy and assess its effect on 14-day mortality among intensive care unit patients.MethodsA single-center retrospective cohort study was conducted on patients admitted to the intensive care unit (ICU) with infectious diseases between January 2018 and December 2020. Patients were stratified into three groups based on the initial treatment regimen within 5 days of antimicrobial administration: ADE, No Change, and Other Change. Confounders between groups were screened using one-way ANOVA and Chi-square analysis. Univariate and multivariate analyses were performed to identify risk factors for 14-day mortality. Potential confounders were balanced using propensity score inverse probability of treatment weighting (IPTW), followed by multivariate logistic regression analysis to evaluate the effect of ADE strategy on 14-day mortality.ResultsA total of 473 patients met the inclusion criteria, with 53 (11.2%) in the ADE group, 173 (36.6%) in the No Change group, and 247 (52.2%) in the Other Change group. The 14-day mortality rates in the three groups were 9.4%, 11.6%, and 21.9%, respectively. After IPTW, the adjusted odds ratio for 14-day mortality comparing No Change with ADE was 1.557 (95% CI 1.078-2.247, P = 0.0181) while comparing Other Change with ADE was 1.282(95% CI 0.884-1.873, P = 0.1874).ConclusionThe prevalence of ADE strategy was low among intensive care unit patients. The ADE strategy demonstrated a protective effect or no adverse effect on 14-day mortality compared to the No Change or Other Change strategies, respectively. These findings provide evidence supporting the implementation of the ADE strategy in ICU patients.
| S-EPMC10401733 | biostudies-literature
Project description:ImportanceHigh health care costs encourage initiatives that avoid overuse of resources and identify opportunities to promote appropriate care.ObjectiveTo investigate the causes of potentially avoidable surgical intensive care unit (SICU) admissions and disposition delays to determine whether targeted interventions could decrease these stays.Design, setting, and participantsThis prospective, observational study focused on potentially avoidable SICU days, as determined by observers with input from the rounding intensivists at a 24-bed open SICU at an urban, academic hospital. The preintervention phase occurred from April 6 through June 21, 2015; after implementation of targeted interventions, the postintervention phase occurred from April 4 through June 28, 2016. Data collected included demographic characteristics, reason for admission, and length of stay. All patients admitted to the SICU during the preintervention and postintervention phases were included in the analysis.InterventionsBased on results collected in the preintervention phase, targeted interventions were designed and implemented from July 1, 2015, through March 31, 2016, including (1) reducing SICU care for minor traumatic brain injury, (2) optimizing postoperative airway management, (3) enhancing communication between services regarding transfers to the SICU, (4) identifying and facilitating more timely end-of-life conversations and supportive care consultations, and (5) encouraging early disposition of patients to floor beds.Main outcomes and measuresChanges in the proportion of potentially avoidable SICU days owing to potentially avoidable admissions and/or disposition delays.ResultsA total of 459 patients (253 men [55.1%] and 206 women [44.9%]; median age, 62 years [interquartile range, 46-75 years]) were admitted during the preintervention and postintervention phases. Of 261 patients admitted during the preintervention period and 245 during the postintervention period, median SICU and hospital length of stay remained unchanged. A reduction was noted in the percentage of postintervention SICU days owing to potentially avoidable admissions (152 of 1168 days [13%] vs 118 of 1338 days [8.8%]; P?=?.001) and disposition delays (138 of 1168 days [11.8%] vs 97 of 1338 days [7.2%]; P?<?.001). During the postintervention period, decreases were noted in the SICU days related to the most common sources of potentially avoidable admissions (SICU stay ?24 hours, airway concerns, and somnolence) and disposition delays (end-of-life decisions and floor bed unavailable) as well as in the overall rate of potentially avoidable days (269 of 1168 days [23%] vs 205 of 1338 days [15.3%]; P?<?.001).Conclusions and relevanceNearly one-fourth of SICU days could be categorized as potentially avoidable. Targeted interventions resulted in a significant reduction of potentially avoidable SICU days.
| S-EPMC5710417 | biostudies-literature
Project description:IntroductionStudies in intensive care unit (ICU) patients have suggested that anemia and blood transfusions can influence outcomes, but these effects have not been widely investigated specifically in surgical ICU patients.MethodsWe retrospectively analyzed the prospectively collected data from all adult patients (>18 years old) admitted to a 50-bed surgical ICU between 1st March 2004 and 30th July 2006.ResultsOf the 5925 patients admitted during the study period, 1833 (30.9%) received a blood transfusion in the ICU. Hemoglobin concentrations were < 9 g/dl on at least one occasion in 57.6% of patients. Lower hemoglobin concentrations were associated with a higher Simplified Acute Physiology Score II and Sequential Organ Failure Assessment score, greater mortality rates, and longer ICU and hospital lengths of stay. Transfused patients had higher ICU (12.5 vs. 3.2%) and hospital (18.3 vs. 6.5%) mortality rates (both p < 0.001) than non-transfused patients. However, ICU and in-hospital mortality rates were similar among transfused and non-transfused matched pairs according to a propensity score (n = 1184 pairs), and after adjustment for possible confounders in a multivariable analysis, higher hemoglobin concentrations (RR 0.97[0.95-0.98], per 1 g/dl, p < 0.001) and blood transfusions (RR 0.96[0.92-0.99], p = 0.031) were independently associated with a lower risk of in-hospital death, especially in patients aged from 66 to 80 years, in patients admitted to the ICU after non-cardiovascular surgery, in patients with higher severity scores, and in patients with severe sepsis.ConclusionsIn this group of surgical ICU patients, anemia was common and was associated with higher morbidity and mortality. Higher hemoglobin concentrations and receipt of a blood transfusion were independently associated with a lower risk of in-hospital death. Randomized control studies are warranted to confirm the potential benefit of blood transfusions in these subpopulations.
| S-EPMC2911729 | biostudies-literature
Project description:BACKGROUND:Prolonged empiric antibiotic use, resulting from diagnostic uncertainties, in suspected early onset sepsis (EOS) cases constitutes a significant problem. Unnecessary antibiotic use increases the risk of antibiotic resistance. Furthermore, prolonged antibiotic use increases the risk of mortality and morbidity in neonates. Proactive measures including empiric antibiotic de-escalation are crucial to overcome these problems. METHODS:This was a prospective cohort study conducted in the neonatal intensive care units of two public hospitals in Malaysia. Neonates with a gestational age greater than 34 weeks who were started on empiric antibiotics within 72 h of life were screened. The data were then stratified according to de-escalation and non-de-escalation practices, where de-escalation practice was defined as narrowing down or discontinuation of empiric antibiotic within 72 h of treatment. RESULTS:A total of 1045 neonates were screened, and 429 were included. The neonates were then divided based on de-escalation (n?=?207) and non-de-escalation (n?=?222) practices. Neonates under non-de-escalation practices showed significantly longer durations of antibiotic use compared to those under de-escalation practices (p?<?0.05), with no difference in treatment outcomes. Five factors were found to be associated with de-escalation of antibiotics. They are cesarean section delivery, exposure to antenatal steroids, nil history of maternal pyrexia, absence of meconium-stained amniotic fluid, and normal C-reactive protein???0.5 mg/dL (p?<?0.05). CONCLUSIONS:Empiric antibiotic de-escalation appears feasible as a routine form of treatment for EOS in late preterm and term neonates.
| S-EPMC7222079 | biostudies-literature
Project description:BackgroundThe present study aimed to assess variables associated to ICU-mortality among patients admitted to surgical intensive care unit in Ethiopia.MethodsA Hospital-based retrospective follow-up study was conducted on all patients who were admitted to the surgical intensive care unit. Data were extracted from patients' charts with a pretested data extraction tool, entered into Epi-data 4.6.0, and analyzed with STATA- 14. Bivariate and multivariate Cox proportional hazards regression models were fitted.ResultsOf the total study participants (388), 148 (38.1%) patients admitted to the surgical intensive care unit died during the follow-up period with a median survival time of 11 days. Potassium level < 3.5 mmol/L (adjusted hazard ratio ( AHR): 3.46, 95% CI (1.83 6.55), potassium level > 5.0 mmol/L (AHR:2.41, 95% CI (1.29-4.51), hypoxia (AHR:1.66, 95% CI (1.10-2.48), Glasgow Coma Scale (GCS) score < 9 (AHR: 4.06, 95% CI (1.51-10.89), mechanical ventilation (AHR:12, 95%CI (3-45), absence of thromboprophylaxis (AHR:10.8,95% CI (6.04-19.29), absence of enteral feeding (AHR:3.56, 95% CI (2.20-5.78) were variables associated with ICU-mortality among patients admitted to surgical intensive care unit.ConclusionsThe overall ICU-mortality of patients admitted to our surgical intensive care unit was higher compared to patients admitted to similar intensive care unit in developed countries. The variables associated to ICU-mortality among patients admitted to surgical intensive care unit were abnormal serum potassium level, lower GCS score, mechanical support, hypoxia, absence of thromboprophylaxis, and enteral feeding.
| S-EPMC10436438 | biostudies-literature
Project description:Shock in cardio-surgical intensive care unit (ICU) patients requires prompt identification of the underlying condition and timely therapeutic interventions. Management during the first 6 hours, also referred to as "the golden hours", is of paramount importance to reverse the shock state and improve the patient's outcome. The authors have previously described a state-of-the-art diagnostic work-up and discussed how to optimise preload, vascular tone, contractility, heart rate and oxygen delivery during this phase. Ideally, shock can be reversed during this initial period. However, some patients might have developed multiple organ dysfunction, which persists beyond the first 6 hours despite the early haemodynamic treatment goals having been accomplished. This period, also referred to as "the silver days", is the focus of this review. The authors discuss how to reduce vasopressor load and how to minimise adrenergic stress by using alternative inotropes, extracorporeal life-support and short acting beta-blockers. The review incorporates data on fluid weaning, safe ventilation, daily interruption of sedation, delirium management and early rehabilitation. It includes practical recommendations in areas where the evidence is scarce or controversial. Although the focus is on cardio-surgery ICU patients, most of the considerations apply to critical ill patients in general.
| S-EPMC5491038 | biostudies-other
Project description:IntroductionEnd-stage renal disease (ESRD) is associated with an increased propensity for critical illness, but whether ESRD is independently associated with a greater risk of death after major surgical procedures is unclear.MethodsThis was a retrospective analysis of prospectively collected data from all adult (>18 years) patients admitted to a 50-bed surgical intensive care unit (ICU) between January 2004 and January 2009. ESRD was defined as the need for chronic peritoneal dialysis or hemodialysis for at least 6 weeks prior to ICU admission. We used multivariable logistic regression analysis and propensity-score matching to adjust for possible confounders.ResultsIn total, 12,938 adult patients were admitted during the study period; 199 patients had ESRD at ICU admission, giving a prevalence of 1.5%. Patients with ESRD were more likely to be male (72.9% versus 63.0%, P?=?0.004) and had higher severity scores, a higher incidence of diabetes mellitus and cirrhosis, and a lower incidence of cancer at ICU admission than those without ESRD. Patients with ESRD were more likely to have any type of organ failure at ICU admission and during the ICU stay. Patients with ESRD had higher ICU and hospital mortality rates (23.1% and 31.2% versus 5.5% and 10.0%, respectively, P <0.001 pairwise) and longer ICU length of stay (2 (1 to 7) versus 1 (1 to 3) days, P <0.001). In multivariable logistic regression analysis, ESRD was independently associated with a greater risk of in-hospital death (odds ratio?=?3.84, 95% confidence interval 2.68 to 5.5, P <0.001). In 199 pairs of patients, hematologic and hepatic failures were more prevalent, ICU and hospital mortality rates were higher (23.1% versus 15.1% and 31.2% versus 19.1%, P <0.05 pairwise), and ICU length of stay was longer (2 (1 to 7) versus 1 (1 to 7) days, P <0.001) in patients with ESRD.ConclusionsIn this large cohort of surgical ICU patients, presence of ESRD at ICU admission was associated with greater morbidity and mortality and independently associated with a greater risk of in-hospital death. Our data can be useful in preoperative risk stratification.
| S-EPMC4057028 | biostudies-literature