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Observational Study
. 2020 Dec 1;75(12):3665-3674.
doi: 10.1093/jac/dkaa375.

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

Christina Routsi  1   2 , Aikaterini Gkoufa  2 , Kostoula Arvaniti  3 , Stelios Kokkoris  1 , Alexandros Tourtoglou  4 , Vassiliki Theodorou  5 , Anna Vemvetsou  3 , Georgios Kassianidis  6 , Athena Amerikanou  6 , Elisabeth Paramythiotou  7 , Efstathia Potamianou  8 , Kyriakos Ntorlis  9 , Angeliki Kanavou  10 , Georgios Nakos  11 , Eleftheria Hassou  12 , Helen Antoniadou  12 , Ilias Karaiskos  2   13 , Athanasios Prekates  4 , Apostolos Armaganidis  7 , Ioannis Pnevmatikos  5 , Miltiades Kyprianou  14 , Spyros Zakynthinos  1 , Garyfallia Poulakou  2   15 , Helen Giamarellou  2   13
Affiliations
Observational Study

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

Christina Routsi et al. J Antimicrob Chemother. .

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.

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