Enhanced antimicrobial de-escalation for pneumonia in mechanically ventilated patients: a cross-over study

Abstract

BackgroundAntibiotics are commonly administered to hospitalized patients with infiltrates for possible bacterial pneumonia, often leading to unnecessary treatment and increasing the risk for resistance emergence. Therefore, we performed a study to determine if an enhanced antibiotic de-escalation practice could improve antibiotic utilization in mechanically ventilated patients with suspected pneumonia cared for in an academic closed intensive care unit (ICU).MethodsThis was a prospective cross-over trial comparing routine antibiotic management (RAM) and enhanced antimicrobial de-escalation (EAD) performed within two medical ICUs (total 34 beds) at Barnes-Jewish Hospital, an academic referral center. Patients in the EAD group had their antibiotic orders and microbiology results reviewed daily by a dedicated team comprised of a second-year critical care fellow, an ICU attending physician and an ICU pharmacist. Antibiotic de-escalation recommendations were made when appropriate based on microbiologic test results and clinical response to therapy.ResultsThere were 283 patients evaluable, with suspected pneumonia requiring mechanical ventilation: 139 (49.1%) patients in the RAM group and 144 (50.9%) in the EAD group. Early treatment failure based on clinical deterioration occurred in 33 (23.7%) and 40 (27.8%) patients, respectively (P = 0.438). In the remaining patients, antimicrobial de-escalation occurred in 70 (66.0%) and 70 (67.3%), respectively (P = 0.845). There was no difference between groups in total antibiotic days ((median (interquartile range)) 7.0 days (4.0, 9.0) versus 7.0 days (4.0, 8.8) (P = 0.616)); hospital mortality (25.2% versus 35.4% (P = 0.061)); or hospital duration (12.0 days (6.0, 20.0) versus 11.0 days (6.0, 22.0) (P = 0.918).ConclusionsThe addition of an EAD program to a high-intensity daytime staffing model already practicing a high-level of antibiotic stewardship in an academic ICU was not associated with greater antibiotic de-escalation or a reduction in the overall duration of antibiotic therapy.Trial registrationClinicalTrials.gov, NCT02685930. Registered on 26 January 2016.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-017-1772-4) contains supplementary material, which is available to authorized users.

Novel Approaches to Hasten Detection of Pathogens and Antimicrobial Resistance in the Intensive Care Unit

“…Despite this lack of overall evidence, ADE has been demonstrated to be safely and effectively performed in critically ill patients. [98][99][100][101] RDTs have the potential for further increasing the role of ADE in the ICU. However, to date there has been limited experience employing RDTs as a de-escalation tool in the critically ill population.…”

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

“…No difference was also observed in 28-day mortality (31% with ADE group versus 23% with treatment continuation, p = 0.55) [4]. Among the 20 observational studies, differences in mortality between ADE and non-ADE were found to be not statistically significant in 14 studies and significantly decreased in the deescalation arm in six studies [6,7,12,13,20,23]. None showed an increased mortality associated with ADE.…”

“…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].…”

Does enhanced antibiotic de-escalation really have no benefit in the ICU?

“…In a recent issue of Critical Care , we read with interest the article by Trupka et al [ 1 ], who investigated the utility of an enhanced antimicrobial de-escalation (EAD) program in mechanically ventilated patients with suspected pneumonia. They found that the EAD program did not affect the rate of antibiotic de-escalation or the duration of antibiotic therapy in intensive care units (ICUs).…”