@article{3020620,
    title = "De-escalation of antimicrobial therapy in ICU settings with high prevalence of multidrug-resistant bacteria: A multicentre prospective observational cohort study in patients with sepsis or septic shock",
    author = "Routsi, C. and Gkoufa, A. and Arvaniti, K. and Kokkoris, S. and Tourtoglou, A. and Theodorou, V. and Vemvetsou, A. and Kassianidis, G. and Amerikanou, A. and Paramythiotou, E. and Potamianou, E. and Ntorlis, K. and Kanavou, A. and Nakos, G. and Hassou, E. and Antoniadou, H. and Karaiskos, I. and Prekates, A. and Armaganidis, A. and Pnevmatikos, I. and Kyprianou, M. and Zakynthinos, S. and Poulakou, G. and Giamarellou, H.",
    journal = "Journal of Antimicrobial Chemotherapy (JAC)",
    year = "2020",
    volume = "75",
    number = "12",
    pages = "3665-3674",
    publisher = "Oxford University Press",
    issn = "0305-7453, 1460-2091",
    doi = "10.1093/jac/dkaa375",
    keywords = "aminoglycoside;  antibiotic agent;  carbapenem;  cephalosporin;  colistin;  glycopeptide;  linezolid;  piperacillin plus tazobactam;  quinolone derivative;  tigecycline;  antiinfective agent, Acinetobacter baumannii;  adult;  all cause mortality;  antibiotic resistance;  antibiotic sensitivity;  antimicrobial therapy;  Article;  Candida;  clinical outcome;  cohort analysis;  controlled study;  critically ill patient;  drug withdrawal;  Enterococcus;  Escherichia coli;  female;  hospital mortality;  human;  intensive care unit;  Klebsiella pneumoniae;  major clinical study;  male;  middle aged;  multicenter study;  multidrug resistant bacterium;  observational study;  prospective study;  Pseudomonas aeruginosa;  sepsis;  septic shock;  Sequential Organ Failure Assessment Score;  Staphylococcus aureus;  superinfection;  treatment duration;  aged;  bacterium;  clinical trial;  intensive care unit;  prevalence, Aged;  Anti-Bacterial Agents;  Bacteria;  Humans;  Intensive Care Units;  Middle Aged;  Prevalence;  Prospective Studies;  Sepsis;  Shock, Septic",
    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. © The Author(s) 2020."
}