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. 2025 Feb 5;80(1):108-117.
doi: 10.1093/cid/ciae591.

Epidemiology and Outcomes of Antibiotic De-escalation in Patients With Suspected Sepsis in US Hospitals

Kai Qian Kam  1   2   3 , Tom Chen  1 , Sameer S Kadri  4   5 , Alexander Lawandi  4   6 , Christina Yek  4   5 , Morgan Walker  4   5 , Sarah Warner  4   5 , David Fram  7 , Huai-Chun Chen  7 , Claire N Shappell  8 , Laura DelloStritto  1 , Robert Jin  1 , Michael Klompas  1   9 , Chanu Rhee  1   9
Affiliations

Epidemiology and Outcomes of Antibiotic De-escalation in Patients With Suspected Sepsis in US Hospitals

Kai Qian Kam et al. Clin Infect Dis. .

Abstract

Background: Little is known about the frequency, hospital-level variation, predictors, and outcomes of antibiotic de-escalation in suspected sepsis.

Methods: We retrospectively analyzed adults admitted to 236 US hospitals from 2017-2021 with suspected sepsis (defined by blood culture draw, lactate measurement, and intravenous antibiotic administration) who were initially treated with ≥2 days of anti-methicillin-resistant Staphylococcus aureus (MRSA) and anti-pseudomonal antibiotics but had no resistant organisms that required these agents identified through hospital day 4. De-escalation was defined as stopping anti-MRSA and anti-pseudomonal antibiotics or switching to narrower antibiotics by day 4. We created a propensity score for de-escalation using 82 hospital and clinical variables; matched de-escalated to non-de-escalated patients; and assessed associations between de-escalation and outcomes.

Results: Among 124 577 patients, antibiotics were de-escalated in 36 806 (29.5%): narrowing in 27 177 (21.8%), cessation in 9629 (7.7%). De-escalation rates varied between hospitals (median, 29.4%; interquartile range, 21.3%-38.0%). Predictors of de-escalation included less severe disease on day 3-4, positive cultures for nonresistant organisms, and negative/absent MRSA nasal swabs. De-escalation was more common in medium, large, and teaching hospitals in the Northeast and Midwest. De-escalation was associated with lower adjusted risks for acute kidney injury (AKI) (odds ratio [OR], 0.80; 95% confidence interval [CI], .76-.84), intensive-care unit (ICU) admission after day 4 (OR, 0.59; 95% CI, .52-.66), and in-hospital mortality (OR, 0.92; 95% CI, .86-.996).

Conclusions: Antibiotic de-escalation in suspected sepsis is infrequent, variable across hospitals, linked with clinical and microbiologic factors, and associated with lower risk for AKI, ICU admission, and in-hospital mortality.

Keywords: antibiotic de-escalation; antibiotics; antimicrobial stewardship; outcomes; sepsis.

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Conflict of interest statement

Potential conflicts of interest . C. R. and M. K. report royalties from UpToDate. C. R. reports payments from the Infectious Diseases Society of America for his role as an associate editor of Clinical Infectious Diseases. All other authors report no potential conflicts.

All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.

Comment in

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