Zaira R Palacios-Baena1, Mercedes Delgado-Valverde1, Adoración Valiente Méndez1, Benito Almirante2, Silvia Gómez-Zorrilla3, Núria Borrell4, Juan E Corzo5, Mercedes Gurguí6, Cristina De la Calle7, Lara García-Álvarez8, Lucía Ramos9, Mónica Gozalo10, María Isabel Morosini11, José Molina12, Manuel Causse13, Álvaro Pascual1, Jesús Rodríguez-Baño1. 1. Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen Macarena, Departamentos de Medicina y Microbiología, Universidad de Sevilla and Instituto de Biomedicina de Sevilla. 2. Servei de Malalties Infeccioses, Hospital Universitari Vall d'Hebron, Barcelona. 3. Servei de Malalties Infeccioses, Hospital de Bellvitge, Barcelona. 4. Servicio de Microbiología, Hospital Universitario Son Espases, Palma de Mallorca, Islas Baleares. 5. Unidad Clínica Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen de Valme, Sevilla. 6. Unitat de Malaties Infeccioses, Hospital de la Santa Creu i Sant Pau. 7. Servei de Malaties Infeccioses, Hospital Clinic i Provincial, Barcelona. 8. Departamento de Enfermedades Infecciosas, Hospital San Pedro-Centro de Investigación Biomédica de La Rioja, Logroño. 9. Servicio de Microbiología, Hospital Universitario A Coruña, Santander. 10. Servicio de Microbiología, Hospital Marqués de Valdecilla-Instituto de Investigación Sanitaria Valdecilla, Santander. 11. Servicio de Microbiología, Hospital Ramón y Cajal, Madrid. 12. Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen del Rocío, Universidad de Sevilla and Instituto de Biomedicina de Sevilla. 13. Unidad de Gestión Clínica de Microbiología, Hospital Universitario Reina Sofía, Instituto Maimónides de Investigación Clínica, Universidad de Córdoba, Spain.
Abstract
BACKGROUND: More data are needed about the safety of antibiotic de-escalation in specific clinical situations as a strategy to reduce exposure to broad-spectrum antibiotics. The aims of this study were to investigate predictors of de-escalation and its impact on the outcome of patients with bloodstream infection due to Enterobacteriaceae (BSI-E). METHODS: A post hoc analysis was performed on a prospective, multicenter cohort of patients with BSI-E initially treated with ertapenem or antipseudomonal β-lactams. Logistic regression was used to analyze factors associated with early de-escalation (EDE) and Cox regression for the impact of EDE and late de-escalation (LDE) on 30-day all-cause mortality. A propensity score (PS) for EDE vs no de-escalation (NDE) was calculated. Failure at end of treatment and length of hospital stay were also analyzed. RESULTS: Overall, 516 patients were included. EDE was performed in 241 patients (46%), LDE in 95 (18%), and NDE in 180 (35%). Variables independently associated with a lower probability of EDE were multidrug-resistant isolates (odds ratio [OR], 0.50 [95% confidence interval {CI}, .30-.83]) and nosocomial infection empirically treated with imipenem or meropenem (OR, 0.35 [95% CI, .14-.87]). After controlling for confounders, EDE was not associated with increased risk of mortality; hazard ratios (HR) (95% CIs) were as follows: general model, 0.58 (.25-1.31); model with PS, 0.69 (.29-1.65); and PS-based matched pairs, 0.98 (.76-1.26). LDE was not associated with mortality. De-escalation was not associated with clinical failure or length of hospital stay. CONCLUSIONS: De-escalation in patients with monomicrobial bacteremia due to Enterobacteriaceae was not associated with a detrimental impact on clinical outcome.
BACKGROUND: More data are needed about the safety of antibiotic de-escalation in specific clinical situations as a strategy to reduce exposure to broad-spectrum antibiotics. The aims of this study were to investigate predictors of de-escalation and its impact on the outcome of patients with bloodstream infection due to Enterobacteriaceae (BSI-E). METHODS: A post hoc analysis was performed on a prospective, multicenter cohort of patients with BSI-E initially treated with ertapenem or antipseudomonal β-lactams. Logistic regression was used to analyze factors associated with early de-escalation (EDE) and Cox regression for the impact of EDE and late de-escalation (LDE) on 30-day all-cause mortality. A propensity score (PS) for EDE vs no de-escalation (NDE) was calculated. Failure at end of treatment and length of hospital stay were also analyzed. RESULTS: Overall, 516 patients were included. EDE was performed in 241 patients (46%), LDE in 95 (18%), and NDE in 180 (35%). Variables independently associated with a lower probability of EDE were multidrug-resistant isolates (odds ratio [OR], 0.50 [95% confidence interval {CI}, .30-.83]) and nosocomial infection empirically treated with imipenem or meropenem (OR, 0.35 [95% CI, .14-.87]). After controlling for confounders, EDE was not associated with increased risk of mortality; hazard ratios (HR) (95% CIs) were as follows: general model, 0.58 (.25-1.31); model with PS, 0.69 (.29-1.65); and PS-based matched pairs, 0.98 (.76-1.26). LDE was not associated with mortality. De-escalation was not associated with clinical failure or length of hospital stay. CONCLUSIONS: De-escalation in patients with monomicrobial bacteremia due to Enterobacteriaceae was not associated with a detrimental impact on clinical outcome.
Authors: Alexis Tabah; Matteo Bassetti; Marin H Kollef; Jean-Ralph Zahar; José-Artur Paiva; Jean-Francois Timsit; Jason A Roberts; Jeroen Schouten; Helen Giamarellou; Jordi Rello; Jan De Waele; Andrew F Shorr; Marc Leone; Garyphallia Poulakou; Pieter Depuydt; Jose Garnacho-Montero Journal: Intensive Care Med Date: 2019-11-28 Impact factor: 17.440