Antibiotics De-Escalation in the Treatment of Ventilator-Associated Pneumonia in Trauma Patients

Abstract

Background:Antimicrobial de-escalation refers to starting the antimicrobial treatment with broad-spectrum antibiotics, followed by narrowing the drug spectrum according to culture results. The present study evaluated the effect of de-escalation on ventilator-associated pneumonia (VAP) in trauma patients.Methods:This retrospective study was conducted on trauma patients with VAP, who received de-escalation therapy (de-escalation group) or non-de-escalation therapy (non-de-escalation group). Propensity score matching method was used to balance the baseline characteristics between both groups. The 28-day mortality, length of hospitalization and Intensive Care Unit stay, and expense of antibiotics and hospitalization between both groups were compared. Multivariable analysis explored the factors that influenced the 28-day mortality and implementation of de-escalation.Results:Among the 156 patients, 62 patients received de-escalation therapy and 94 patients received non-de-escalation therapy. No significant difference was observed in 28-day mortality between both groups (28.6% vs. 23.8%, P = 0.620). The duration of antibiotics treatment in the de-escalation group was shorter than that in the non-de-escalation group (11 [8–13] vs. 14 [8–19] days, P = 0.045). The expenses of antibiotics and hospitalization in de-escalation group were significantly lower than that in the non-de-escalation group (6430 ± 2730 vs. 7618 ± 2568 RMB Yuan, P = 0.043 and 19,173 ± 16,861 vs. 24,184 ± 12,039 RMB Yuan, P = 0.024, respectively). Multivariate analysis showed that high Acute Physiology and Chronic Health Evaluation II (APACHE II) score, high injury severity score, multi-drug resistant (MDR) infection, and inappropriate initial antibiotics were associated with patients' 28-day mortality, while high APACHE II score, MDR infection and inappropriate initial antibiotics were independent factors that prevented the implementation of de-escalation.Conclusions:De-escalation strategy in the treatment of trauma patients with VAP could reduce the duration of antibiotics treatments and expense of hospitalization, without increasing the 28-day mortality and MDR infection.

Impact of antimicrobial de-escalation on mortality: a literature review of study methodology and recommendations for observational studies

“…The effect estimates obtained in these multivariable analyses are depicted in Figure 1, clustered by study population. Studies that did not present an OR, HR, or RR in their article [45,50,56] are not included. The confidence intervals between the different studies per study population overlap largely and the point estimates are mostly in favor of de-escalation.…”

“…For 33 studies solely reporting crude estimates on mortality, we confine ourselves by stating that they suffer from severe confounding by indication and are of no use for a causal inference. For the remaining we discuss studies that adjusted for potential confounders (N = 19) [15,20,21,27,28,31,33,34,40,43,[45][46][47]50,53,56,57,60,61]. For the purpose of this review, we focus on three main issues: (1) lack of adjustment for the patients' clinical course, (2) modeling deescalation as a fixed variable, and (3) modeling time-varying confounders as fixed variables.…”

Antimicrobial De-Escalation in the ICU: From Recommendations to Level of Evidence

“…We identified one randomized controlled trial (RCT) [4] and 20 observational studies describing ADE in ICU patients [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24]. We excluded studies evaluating antifungal de-escalation alone as well as case reports, case series and reviews.…”

“…Six observational studies, which did not include early cessation of antimicrobials in the definition of ADE, reported on these outcomes (n trials = 6, n patients = 1444). Three showed similar durations of antibiotic treatment [5,10,13], two showed an increase in duration with ADE [11,24] and one showed a decrease in duration with ADE [15].…”

Altering Routine Intensive Care Unit Practices to Support Commensalism

“…Although most studies included were of low quality, no mortality difference was seen between de‐escalation and non–de‐escalation, and some students favored de‐escalation for better survival 56 . In trauma patients being treated for VAP, de‐escalation of antibiotics was associated with shorter treatment durations and decreased antibiotic expenditures with no increase in 28‐day mortality 57 . The indiscriminant use of broad‐spectrum antimicrobial agents can have deleterious effects on the gut microbiome and reduce beneficial GI flora.…”