TY - JOUR
TI - 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
AU - Routsi, C.
AU - Gkoufa, A.
AU - Arvaniti, K.
AU - Kokkoris, S.
AU - Tourtoglou, A.
AU - Theodorou, V.
AU - Vemvetsou, A.
AU - Kassianidis, G.
AU - Amerikanou, A.
AU - Paramythiotou, E.
AU - Potamianou, E.
AU - Ntorlis, K.
AU - Kanavou, A.
AU - Nakos, G.
AU - Hassou, E.
AU - Antoniadou, H.
AU - Karaiskos, I.
AU - Prekates, A.
AU - Armaganidis, A.
AU - Pnevmatikos, I.
AU - Kyprianou, M.
AU - Zakynthinos, S.
AU - Poulakou, G.
AU - Giamarellou, H.
JO - Journal of Antimicrobial Chemotherapy (JAC)
PY - 2020
VL - 75
TODO - 12
SP - 3665-3674
PB - Oxford University Press
SN - 0305-7453, 1460-2091
TODO - 10.1093/jac/dkaa375
TODO - 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
TODO - 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.
ER -