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

Abstract

Antimicrobial de-escalation (ADE) is a component of antimicrobial stewardship (AMS) aimed to reduce exposure to broad-spectrum antimicrobials. In the intensive care unit, ADE is a strong recommendation that is moderately applied in clinical practice. Following a systematic review of the literature, we assessed the studies identified on the topic which included one randomized controlled trial and 20 observational studies. The literature shows a low level of evidence, although observational studies suggested that this procedure is safe. The effects of ADE on the level of resistance of ecological systems and especially on the microbiota are unclear. The reviewers recommend de-escalating antimicrobial treatment in patients requiring long-term antibiotic therapy and considering de-escalation in short-term treatments.

Point Prevalence Survey of Antimicrobial Use in Four Tertiary Care Hospitals in Mexico

“… 33 Besides, although the microbiology laboratories’ role and rate of antimicrobial cultures per patient varied widely among the hospitals surveyed, none of them appears to have used the culture results and AST data for de-escalation of the antibiotic therapies, as recommended to reduce detrimental effects on patients as well as to minimize the development of AMR. 34 …”

“…33 Besides, although the microbiology laboratories' role and rate of antimicrobial cultures per patient varied widely among the hospitals surveyed, none of them appears to have used the culture results and AST data for de-escalation of the antibiotic therapies, as recommended to reduce detrimental effects on patients as well as to minimize the development of AMR. 34 All the above could represent a common scenario associated to the recurrent identification of MDR E. coli and ESKAPE pathogens in the hospitals surveyed, as well as in other Mexican hospitals. 16,17,35,36 We consider that our findings could be partly explained by the absence of formally established ASPs in the hospitals surveyed.…”

Antimicrobial Stewardship Program: Reducing Antibiotic’s Spectrum of Activity Is not the Solution to Limit the Emergence of Multidrug-Resistant Bacteria

“…In fact, many authors have attempted to define and classify the ecological effects linked to the administration of different antibiotics [ 54 , 55 ]. However, the proposed classification was based on experts’ opinion and seemed to be influenced by regional epidemiological resistance data [ 6 ]. Moreover, as far as we know, despite the large number of studies suggesting the safety of de-escalation [ 56 , 57 , 58 ], its ecological benefits and effects on intestinal microbiota and on MDRO acquisition have never been demonstrated [ 6 ].…”

“…However, the proposed classification was based on experts’ opinion and seemed to be influenced by regional epidemiological resistance data [ 6 ]. Moreover, as far as we know, despite the large number of studies suggesting the safety of de-escalation [ 56 , 57 , 58 ], its ecological benefits and effects on intestinal microbiota and on MDRO acquisition have never been demonstrated [ 6 ]. More surprisingly, in a recent literature review aiming to identify risk factors associated with the acquisition and emergence of CRE, the authors suggested a correlation between the use of carbapenems and the high risk of acquisition.…”

“…With the spread of extended-spectrum beta-lactamase-producing Enterobacterales (ESBL-PE), this policy has been intensified and it is characterized by a willingness to spare certain classes of antibiotics (e.g., carbapenems) in favor of other classes of antibiotics that have a narrower spectrum, and therefore less ecological consequences [ 4 , 5 ]. Although several authors have tried to rank the different antibiotic classes based on the concept of “narrow or broad-spectrum”, this classification remains controversial [ 6 ] as authors seem to confuse the spectrum of activity and the ecological effect of the different antibiotic classes. Recently, with the deepening of our knowledge of the intestinal microbiota and our better understanding of the factors that participate in the mechanism of resistance to colonization [ 7 ], authors have challenged this concept by arguing that different classes of antibiotics could have the same ecological effects [ 8 , 9 , 10 ].…”