Elaboration of a consensual definition of de-escalation allowing a ranking of β-lactams

Abstract

Empirical broad spectrum antimicrobial therapy prescribed in life-threatening situations should be de-escalated to mitigate the risk of resistance emergence. Definitions of de-escalation (DE) vary among studies, thereby biasing their results. The aim of this study was to provide a consensus definition of DE and to establish a ranking of β-lactam according to both their spectra and their ecological consequences. Twenty-eight experts from intensive care, infectious disease and clinical microbiology were consulted using the Delphi method (four successive questionnaires) from July to November 2013. More than 70% of similar answers to a question were necessary to reach a consensus. According to our consensus definition, DE purpose was to reduce both the spectrum of antimicrobial therapy and the selective pressure on microbiota. DE included switching from combination to monotherapy. A six-rank consensual classification of β-lactams allowing gradation of DE was established. The group was unable to differentiate ecological consequences of molecules included in group 4, i.e. piperacillin/tazobactam, ticarcillin/clavulanic acid, fourth-generation cephalosporin and antipseudomonal third-generation cephalosporin. Furthermore, no consensus was reached on the delay within which DE should be performed and on whether or not the shortening of antibiotic therapy duration should be included in DE definition. This study provides a consensual ranking of β-lactams according to their global ecological consequences that may be helpful in future studies on DE. However, this work also underlines the difficulties of reaching a consensus on the relative ecological impact of each individual drug and on the timing of DE.

Carbapenem use in French hospitals: A nationwide survey at the patient level

“…Second, we did not consider ertapenem as de-escalation, in contrast to other studies. However, there is no consensus regarding the definition of de-escalation [15] and only a small number of patients received ertapenem as second carbapenem, which is likely not to impact the results. Third, the study was performed before the implementation of the new European Committee on Antimicrobial Susceptibility Testing (EUCAST) guidelines recommending interpreting the susceptibility of ESBL-EB to ESCs based on MICs results, and not as systematically non-susceptible (http://www.eucast.org/clinical breakpoints/).…”

Impact of rapid identification of positive blood cultures using the Verigene system on antibiotic prescriptions: A prospective study of community-onset bacteremia in a tertiary hospital in Japan

“…Episodes of bacteremia due to gram-positive bacteria (GP) and gram-negative bacteria (GN) in the same patient were counted separately. De-escalation was defined according to a previously described ranking of β-lactams [9]. In addition, reducing the numbers of antibiotics (e.g., vancomycin and ceftriaxone to ceftriaxone), switching from third- or fourth-generation cephalosporins to first-generation cephalosporins, switching from first-generation cephalosporins to penicillin (including aminopenicillin) and switching from aminopenicillin to penicillin G were also considered de-escalation.…”

Evaluation of early antimicrobial therapy adaptation guided by the BetaLACTA® test: a case-control study

“…According to the beta-lactam classes defined by Weiss and colleagues [19], an “optimal antimicrobial therapy” was defined as the use of amoxicillin, amoxicillin/clavulanate or cefotaxime for wild-type Enterobacteriaceae; cefepime for AmpC-overproducing Enterobacteriaceae ; and carbapenem for ESBL-producing Enterobacteriaceae .…”