A systematic review of the definitions, determinants and clinical outcomes of antimicrobial de-escalation in the intensive care unit.
Clin Infect Dis. 2015 Dec 23;
Authors: Tabah A, Cotta MO, Garnacho-Montero J, Schouten J, Roberts JA, Lipman J, Tacey M, Timsit JF, Leone M, Zahar JR, De Waele J, Working Group for Antimicrobial Use in the ICU
De-escalation (DE) is a strategy to reduce the spectrum of antimicrobials and aims to prevent the emergence of bacterial resistance. We present a systematic review describing the definitions, determinants and outcomes associated with DE. We included 2 RCTs and 12 cohort studies. There was considerable variability in the definition of DE. It was more frequently performed in patients with broad-spectrum and/or appropriate antimicrobial therapy (p=0.05 to 0.002), when more agents were used (p=0.002), in the absence of MDR pathogens (p<0.05). Where investigated, lower or improving severity scores were consistently associated with DE (p=0.04 to <0.001). The pooled effect of DE on mortality is protective (RR 0.68, 95% CI 0.52-0.88). As the determinants of DE are markers of clinical improvement and/or of lower risk of treatment failure this effect on mortality cannot be retained as evidence. None of the studies were designed to investigate the effect of DE on antimicrobial resistance.
PMID: 26703860 [PubMed - as supplied by publisher]