Safety and Feasibility of Antibiotic De-escalation in Critically Ill Children With Sepsis – A Prospective Analytical Study From a Pediatric ICU

Abstract

Introduction: De-escalation is the key to balance judicious antibiotic usage for life-threatening infections and reducing the emergence of antibiotic resistance caused by antibiotic overuse. Robust evidence is lacking regarding the safety of antibiotic de-escalation in culture negative sepsis.Materials and Methods: Children admitted to the PICU during the first 6 months of 2019 with suspected infection were included. Based on the clinical condition, cultures and septic markers, antibiotics were de-escalated or continued at 48–72 h. Outcome data like worsening of primary infection, acquisition of hospital acquired infection, level of ICU support and mortality were captured.Results: Among the 360 admissions, 247 (68.6%) children received antibiotics. After excluding 92 children, 155 children with 162 episodes of sepsis were included in the study. Thirty four episodes were not eligible for de-escalation. Among the eligible group of 128 episodes, antibiotics were de-escalated in 95 (74.2%) and continued in 33 (25.8%). The primary infection worsened in 5 (5.2%) children in the de-escalation group and in 1 (3%) in non de-escalation group [Hazard ratio: 2.12 (95%CI: 0.39–11.46)]. There were no significant differences in rates of hospital acquired infection, mortality or length of ICU stay amongst the groups. Blood cultures and assessment of clinical recovery played a major role in de-escalation of antibiotics and the clinician's hesitation to de-escalate in critically ill culture negative children was the main reason for not de-escalating among eligible children.Conclusion: Antibiotic de-escalation appears to be a safe strategy to apply in criticallly ill children, even in those with negative cultures.

Antimicrobial Step-Down Therapy versus Conventional Antimicrobial Therapy in the Treatment of Patients with Sepsis

“…The results indicate that the antimicrobial step-down therapy features a promising clinical Step-down therapy is an empirical anti-infective regimen with the following two characteristics: (1) a single, broad-spectrum, potent antibiotic is used at the beginning of anti-infective therapy to cover as many germs as possible that may cause the infection; (2) after 48-72 h, the antibiotics are adjusted according to the results of microbiological examination of drug sensitivity to be more targeted. It is a new treatment strategy adopted in recent years for severe bacterial infections [21,22]. The strategy consists of two phases: the first phase is empirical treatment with broadspectrum antibiotics, and the second phase is downgrading to a relatively narrow spectrum of antibiotics, which is the adjustment of relatively narrow-spectrum, targeted antibiotic species according to microbiological examination and drug sensitivity results, to shorten the course of treatment, and to maximize the best possible efficacy of anti-infective treatment [23].…”

Usefulness of the Combination of FilmArray and procalcitonin in respiratory infections in the Pediatric Intensive Care Unit

“…In these patients, the role of laboratory tests is vital to help distinguish patients with bacterial infections, guiding decision-making on whether to start, continue, or discontinue the established treatment (6). On the other hand, when further studies cannot con rm bacterial infection and discontinuation of antibiotic treatment may be indicated, our ndings suggest that discontinuation of antibiotics appears to be a safe strategy even in critically ill children (5).…”

“…Approximately, three-quarters of the antibiotic therapies are equivocally prescribed for respiratory infections of viral origin (1,2). This unnecessary use of antibiotics contributes signi cantly to increasing bacterial resistance as well as morbidity and mortality (3,4), and rising health care costs (5). Therefore, methods to detect and distinguish early between bacterial or viral infection are important, as the clinical presentation can often be indistinguishable.…”

“…Therefore, methods to detect and distinguish early between bacterial or viral infection are important, as the clinical presentation can often be indistinguishable. Physical examination, routine microbiological testing of respiratory specimens, and radiological ndings are unreliable for establishing an accurate diagnosis differentiating viral, bacterial, or viral infection with bacterial coinfection (5). In pediatric patients, laboratory tests that help distinguish patients with bacterial infections is a necessary priority, guiding decision-making more precisely about the initiation or continuation of antibacterial treatments (6).…”

Antimicrobial Stewardship Improvement in Pediatric Intensive Care Units in Spain—What Have We Learned?

“…Ying Guo et al [ 26 ] performed a meta-analysis that reported a de-escalation rate of 39.5% for the antibiotics used in adult patients with severe sepsis and this did not have a detrimental impact on mortality. Furthermore, in a recent publication, Battula et al [ 27 ] reported a de-escalation in 59% of the episodes of sepsis admitted to PICUs and concluded that this strategy appears to be safe.…”