De-escalation of pivotal beta-lactam in ventilator-associated pneumonia does not impact outcome and marginally affects MDR acquisition

Weiss, Emmanuel; Zahar, Jean Ralph; Garrouste-Orgeas, Maïté; Ruckly, Stéphane; Essaied, W; Schwebel, Carole; Timsit, Jean François

doi:10.1007/s00134-016-4448-7

Cited by 20 publications

(28 citation statements)

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“…Previous observations indicate that ADE is undertaken more often in patients with an already favorable clinical course, e.g., improving SOFA score, a phenomenon that was also observed in our study [4]. Early clinical improvement may also explain the shorter lengths of stay which we observed in ADE patients compared to patients with no treatment change, a finding that has been inconsistently documented in previous studies and is in contradiction with the results of Leone et al [4,15,34,37,[39][40][41]44]. In contrast to several studies in the literature, we found no difference in mortality between the ADE and "no change" patients [4,13,14].…”

Section: Discussioncontrasting

confidence: 99%

“…Another explanation for the lower than expected ADE rate could be the strict definition of ADE that was used, i.e., ADE applied within the first 3 days of initiation of empirical therapy. Previous studies defined timing of ADE in various ways, e.g., within 3 or 5 days following treatment initiation, or aligned with the timing of microbiology results [15,36,37,[39][40][41][42][43][44][45]. Expanding the ADE time-window to 5 and 7 days would have increased the ADE rate to 21% and 23%, respectively.…”

Section: Discussionmentioning

confidence: 99%

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Antimicrobial de-escalation in the critically ill patient and assessment of clinical cure: the DIANA study

et al. 2020

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Purpose: The DIANA study aimed to evaluate how often antimicrobial de-escalation (ADE) of empirical treatment is performed in the intensive care unit (ICU) and to estimate the effect of ADE on clinical cure on day 7 following treatment initiation. Methods: Adult ICU patients receiving empirical antimicrobial therapy for bacterial infection were studied in a prospective observational study from October 2016 until May 2018. ADE was defined as (1) discontinuation of an antimicrobial in case of empirical combination therapy or (2) replacement of an antimicrobial with the intention to narrow the antimicrobial spectrum, within the first 3 days of therapy. Inverse probability (IP) weighting was used to account for time-varying confounding when estimating the effect of ADE on clinical cure. Results: Overall, 1495 patients from 152 ICUs in 28 countries were studied. Combination therapy was prescribed in 50%, and carbapenems were prescribed in 26% of patients. Empirical therapy underwent ADE, no change and change other than ADE within the first 3 days in 16%, 63% and 22%, respectively. Unadjusted mortality at day 28 was 15.8% in the ADE cohort and 19.4% in patients with no change [p = 0.27; RR 0.83 (95% CI 0.60-1.14)]. The IP-weighted relative risk estimate for clinical cure comparing ADE with no-ADE patients (no change or change other than ADE) was 1.37 (95% CI 1.14-1.64). Conclusion: ADE was infrequently applied in critically ill-infected patients. The observational effect estimate on clinical cure suggested no deleterious impact of ADE compared to no-ADE. However, residual confounding is likely.

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Section: Discussioncontrasting

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Antimicrobial de-escalation in the critically ill patient and assessment of clinical cure: the DIANA study

et al. 2020

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“…However, at an individual level, few studies have shown a link between a decrease in broad-spectrum antibiotic consumption and a decrease in antimicrobial resistance [20][21][22]. A study conducted in an intensive care unit found no decrease in the rate of global multidrug resistant (MDR) strain carriage acquisition after de-escalation of pivotal beta-lactam in ventilator-associated pneumoniae [23]. Reducing antibiotic consumption is an absolute necessity.…”

Section: Introductionmentioning

confidence: 99%

Gut Microbiota, Antibiotic Therapy and Antimicrobial Resistance: A Narrative Review

2020

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Antimicrobial resistance is a major concern. Epidemiological studies have demonstrated direct relationships between antibiotic consumption and emergence/dissemination of resistant strains. Within the last decade, authors confounded spectrum activity and ecological effects and did not take into account several other factors playing important roles, such as impact on anaerobic flora, biliary elimination and sub-inhibitory concentration. The ecological impact of antibiotics on the gut microbiota by direct or indirect mechanisms reflects the breaking of the resistance barrier to colonization. To limit the impact of antibiotic therapy on gut microbiota, consideration of the spectrum of activity and route of elimination must be integrated into the decision. Various strategies to prevent (antimicrobial stewardship, action on residual antibiotics at colonic level) or cure dysbiosis (prebiotic, probiotic and fecal microbiota transplantation) have been introduced or are currently being developed.

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“…Currently, there are several studies regarding the antibiotic de-escalation in medical or surgical patients;[ 10 11 ] however, only a few reports are available in trauma patients. VAP in trauma patients is not completely equivalent to VAP in medical or surgical patients and exhibits specific features.…”

Section: Discussionmentioning

confidence: 99%

“…These findings were similar to studies focused on medical and surgical VAP patients. [ 11 17 ] Although a systemic review[ 18 ] showed that de-escalation exerted a protective effect on mortality, the authors revealed that this effect might be attributed to clinical improvement or low risk of treatment failure, and thus, could not be retained as evidence. Moreover, our results showed that the patients' length of hospital and ICU stays, and duration of MV did not differ between the two groups before and after PSM, indicating that de-escalation therapy was a safe strategy.…”

Section: Discussionmentioning

confidence: 99%

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

Yang

Huang

et al. 2018

Chinese Medical Journal

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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.

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De-escalation of pivotal beta-lactam in ventilator-associated pneumonia does not impact outcome and marginally affects MDR acquisition

Cited by 20 publications

References 3 publications

Antimicrobial de-escalation in the critically ill patient and assessment of clinical cure: the DIANA study

Antimicrobial de-escalation in the critically ill patient and assessment of clinical cure: the DIANA study

Gut Microbiota, Antibiotic Therapy and Antimicrobial Resistance: A Narrative Review

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

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