Christina Routsi1,2, Aikaterini Gkoufa2, Kostoula Arvaniti3, Stelios Kokkoris1, Alexandros Tourtoglou4, Vassiliki Theodorou5, Anna Vemvetsou3, Georgios Kassianidis6, Athena Amerikanou6, Elisabeth Paramythiotou7, Efstathia Potamianou8, Kyriakos Ntorlis9, Angeliki Kanavou10, Georgios Nakos11, Eleftheria Hassou12, Helen Antoniadou12, Ilias Karaiskos2,13, Athanasios Prekates4, Apostolos Armaganidis7, Ioannis Pnevmatikos5, Miltiades Kyprianou14, Spyros Zakynthinos1, Garyfallia Poulakou2,15, Helen Giamarellou2,13. 1. 1st Department of Intensive Care, School of Medicine, National and Kapodistrian University of Athens, 'Evangelismos' Hospital, Athens, Greece. 2. Hellenic Society of Antimicrobial Chemotherapy, Greece. 3. Department of Intensive Care, 'Papageorgiou' Hospital, Thessaloniki, Greece. 4. Department of Intensive Care, 'Tzaneio' Hospital, Piraeus, Greece. 5. Department of Intensive Care, Democritus University of Thrace, Alexandroupolis University Hospital, Alexandroupolis, Greece. 6. Department of Intensive Care, 'Red Cross' Hospital, Athens, Greece. 7. 2nd Department of Intensive Care, School of Medicine, National and Kapodistrian University of Athens, 'Attikon' Hospital, Athens, Greece. 8. 1st Department of Respiratory Medicine, Intensive Care Unit, School of Medicine, National and Kapodistrian University of Athens, 'Sotiria' Hospital, Athens, Greece. 9. Department of Intensive Care, 'Konstantopouleio' Hospital, Athens, Greece. 10. Department of Intensive Care, 'Thriassio' Hospital, Elefsina, Greece. 11. Department of Intensive Care, 'Henry Dunant' Hospital Center, Athens, Greece. 12. Department of Intensive Care, 'Gennimatas' Hospital, Thessaloniki, Greece. 13. Hygeia General Hospital, Athens, Greece. 14. Hellenic Institute for the Study of Sepsis, Greece. 15. School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
Abstract
BACKGROUND: De-escalation of empirical antimicrobial therapy, a key component of antibiotic stewardship, is considered difficult in ICUs with high rates of antimicrobial resistance. OBJECTIVES: To assess the feasibility and the impact of antimicrobial de-escalation in ICUs with high rates of antimicrobial resistance. METHODS: Multicentre, prospective, observational study in septic patients with documented infections. Patients in whom de-escalation was applied were compared with patients without de-escalation by the use of a propensity score matching by SOFA score on the day of de-escalation initiation. RESULTS: A total of 262 patients (mean age 62.2 ± 15.1 years) were included. Antibiotic-resistant pathogens comprised 62.9%, classified as MDR (12.5%), extensively drug-resistant (49%) and pandrug-resistant (1.2%). In 97 (37%) patients de-escalation was judged not feasible in view of the antibiotic susceptibility results. Of the remaining 165 patients, judged as patients with de-escalation possibility, de-escalation was applied in 60 (22.9%). These were matched to an equal number of patients without de-escalation. In this subset of 120 patients, de-escalation compared with no de-escalation was associated with lower all-cause 28 day mortality (13.3% versus 36.7%, OR 0.27, 95% CI 0.11-0.66, P = 0.006); ICU and hospital mortality were also lower. De-escalation was associated with a subsequent collateral decrease in the SOFA score. Cox multivariate regression analysis revealed de-escalation as a significant factor for 28 day survival (HR 0.31, 95% CI 0.14-0.70, P = 0.005). CONCLUSIONS: In ICUs with high levels of antimicrobial resistance, feasibility of antimicrobial de-escalation was limited because of the multi-resistant pathogens isolated. However, when de-escalation was feasible and applied, it was associated with lower mortality.
BACKGROUND: De-escalation of empirical antimicrobial therapy, a key component of antibiotic stewardship, is considered difficult in ICUs with high rates of antimicrobial resistance. OBJECTIVES: To assess the feasibility and the impact of antimicrobial de-escalation in ICUs with high rates of antimicrobial resistance. METHODS: Multicentre, prospective, observational study in septic patients with documented infections. Patients in whom de-escalation was applied were compared with patients without de-escalation by the use of a propensity score matching by SOFA score on the day of de-escalation initiation. RESULTS: A total of 262 patients (mean age 62.2 ± 15.1 years) were included. Antibiotic-resistant pathogens comprised 62.9%, classified as MDR (12.5%), extensively drug-resistant (49%) and pandrug-resistant (1.2%). In 97 (37%) patients de-escalation was judged not feasible in view of the antibiotic susceptibility results. Of the remaining 165 patients, judged as patients with de-escalation possibility, de-escalation was applied in 60 (22.9%). These were matched to an equal number of patients without de-escalation. In this subset of 120 patients, de-escalation compared with no de-escalation was associated with lower all-cause 28 day mortality (13.3% versus 36.7%, OR 0.27, 95% CI 0.11-0.66, P = 0.006); ICU and hospital mortality were also lower. De-escalation was associated with a subsequent collateral decrease in the SOFA score. Cox multivariate regression analysis revealed de-escalation as a significant factor for 28 day survival (HR 0.31, 95% CI 0.14-0.70, P = 0.005). CONCLUSIONS: In ICUs with high levels of antimicrobial resistance, feasibility of antimicrobial de-escalation was limited because of the multi-resistant pathogens isolated. However, when de-escalation was feasible and applied, it was associated with lower mortality.
Authors: Angela N Lewis; Diomel de la Cruz; James L Wynn; Lauren C Frazer; William Yakah; Camilia R Martin; Heeju Yang; Elena Itriago; Jana Unger; Amy B Hair; Jessica Miele; Brynne A Sullivan; Ameena Husain; Misty Good Journal: Neonatology Date: 2022-03-21 Impact factor: 4.035