Fewer than 1 in 7 eligible sufferers with pneumonia had their empiric antibiotic protection de-escalated following damaging cultures, in line with a retrospective cohort examine revealed in Scientific infectious Ailments.
Investigators studied sufferers 18 years and older admitted with pneumonia to a hospital taking part within the Premier Healthcare Database between 2010 and 2015. Sufferers with constructive tradition isolates, constructive urine antigen assessments, or constructive polymerase chain response assays had been excluded from participation. All sufferers obtained an empiric anti-methicillin-resistant Staphylococcus aureus (anti-MRSA) drug and no less than 1 antipseudomonal agent (excluding quinolones). De-escalation was outlined as discontinuing each broad-spectrum empiric antimicrobial brokers on hospital day 4 whereas persevering with different antibiotics.
Associations of de-escalation on hospital day 4 had been measured with the next outcomes: all-cause in-hospital mortality from hospital day 5 to 14; day 5 or later intensive care unit (ICU) switch; invasive mechanical air flow; vasopressor use; Clostridioides difficile an infection or a constructive laboratory check for it; size of keep; and value.
Antibiotic re-escalation was outlined as resumption of anti-MRSA or antipseudomonal remedy by day 7 after de-escalation and was measured.
A complete of 14,710 eligible sufferers met the preliminary standards. Typically, anti-MRSA remedy was famous to be de-escalated sooner than antipseudomonal remedy. By day 4, 77 sufferers had died and 12,786 sufferers had been on a broad-spectrum empiric antibiotic. By day 4, 1924 sufferers (13%) discontinued the empiric brokers. By day 10, roughly 65% of sufferers had remedy de-escalated or had been discharged.
De-escalation occurred extra regularly bigger hospitals (9.7%) in contrast with smaller hospitals (5.9%), in educating hospitals (9.7%) in contrast with others (6.3%), and in city hospitals (8.2%) in contrast with rural hospitals (6.9%).
The examine authors discovered the next to be considerably related to de-escalation:
- Much less frequent late ICU admission (odds ratio [OR], 0.38; 95% CI, 0.18-0.79);
- Late invasive mechanical air flow (OR, 0.25; 95% CI, 0.09-0.66);
- Late vasopressor use (OR, 0.13; 95% CI, 0.04-0.44);
- Shorter size of keep (risk-adjusted ratio of means, , 0.76; 95% CI, 0.75-0.78); and
- Decrease hospitalization price (risk-adjusted ratio of means, 0.74; 95% CI, 0.72-0.76).
De-escalation was not considerably related to 14-day mortality (OR, 0.65; 95% CI, 0.39-1.08) or growing C difficile an infection (OR, 1.33; 95% CI, 0.40-4.47).
Re-escalation to broad-spectrum medication occurred in 13 sufferers (1.4%) throughout their hospitalization.
“Taking a look at de-escalation charges throughout hospitals (2-35%) demonstrates that there’s substantial room for enchancment. Particularly, the low charges of de-escalation amongst low-risk culture-negative sufferers spotlight a straightforward goal for antimicrobial stewardship, since near 100% of such sufferers needs to be de-escalated,” the investigators acknowledged.
Limitations of this examine embrace some residual confounding by indication and an absence of scientific information that had been wanted to instantly measure scientific severity.
“Since antibiotics will not be benign and antimicrobial stewardship applications ought to emphasize de-escalation following damaging cultures as a possibility to cut back publicity to broad-spectrum antibiotics, enhancing each antimicrobial stewardship and drugs security by substitution of lower-toxicity brokers,” examine authors concluded.
Disclosure: Some authors have disclosed affiliations with biotech, pharmaceutical, system, and/or different firms. Please see the unique reference for a full record of authors’ disclosures.
Deshpande A, Richter SS, Haessler S, et al. De-escalation of empiric antibiotics following damaging cultures in hospitalized sufferers with pneumonia: charges and outcomes. Clin Infect Dis. 2021;72(8):1314-1322. doi:10.1093/cid/ciaa212