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Clin Infect Dis. 2016 Apr 15;62(8):1009-1017. doi: 10.1093/cid/civ1199. Epub 2015 Dec 23.

A Systematic Review of the Definitions, Determinants, and Clinical Outcomes of Antimicrobial De-escalation in the Intensive Care Unit.

Author information

1
Intensive Care Unit, Royal Brisbane and Women's Hospital.
2
Burns, Trauma, and Critical Care Research Centre.
3
School of Pharmacy, The University of Queensland.
4
Unidad Clínica de Cuidados Intensivos, Hospital Universitario Virgen Macarena, Instituto de Biomedicina de Sevilla, Spain.
5
Department of Intensive Care, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands.
6
Faculty of Health, Queensland University of Technology, Brisbane.
7
Melbourne EpiCentre, Royal Melbourne Hospital and Department of Medicine, University of Melbourne, Australia.
8
APHP - Hopital Bichat - Reanimation Medicale et des Maladies Infectieuses.
9
UMR 1137 - IAME Team 5 - DeSCID: Decision Sciences in Infectious Diseases, Control and Care; Inserm/Univ Paris Diderot, Sorbonne Paris Cité.
10
Service d'Anesthésie et de Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix Marseille Université.
11
Unité de Prévention et de Lutte Contre les Infections Nosocomiales, CHU Angers-Université D'Angers, France.
12
Department of Critical Care Medicine, Ghent University Hospital, Belgium.

Abstract

Antimicrobial de-escalation (ADE) 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 ADE. We included 2 randomized controlled trials and 12 cohort studies. There was considerable variability in the definition of ADE. It was more frequently performed in patients with broad-spectrum and/or appropriate antimicrobial therapy (P= .05 to .002), when more agents were used (P= .002), and in the absence of multidrug-resistant pathogens (P< .05). Where investigated, lower or improving severity scores were consistently associated with ADE (P= .04 to <.001). The pooled effect of ADE on mortality is protective (relative risk, 0.68; 95% confidence interval, .52-.88). Because the determinants of ADE 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 ADE on antimicrobial resistance.

KEYWORDS:

de-escalation; resistance; stewardship; streamlining

PMID:
26703860
DOI:
10.1093/cid/civ1199
[Indexed for MEDLINE]

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