Spencer Roper, PharmD,
PGY2 Critical Care Resident
University of Tennessee Medical Center
Knoxville, Tennessee
Disclosure information not submitted.
David Cretella, PharmD, BCIDP
Pharmacist
University of Mississippi Medical Center, United States
Disclosure information not submitted.
Mary Joyce Wingler, PharmD, BCIDP
Pharmacist
University of Mississippi Medical Center, United States
Disclosure information not submitted.
Jason Parham, MD
Physician
University of Mississippi Medical Center, United States
Disclosure information not submitted.
Title: Antibiotic De-escalation in Critically Ill Patients with Negative Clinical Cultures
INTRODUCTION/HYPOTHESIS:
A majority of patients in adult ICUs receive antibiotics. Broad spectrum antibiotics are often necessary empirically, but each day of therapy increases patients' risk for adverse events and resistance development. For this reason, clinical guidelines recommend antibiotic de-escalation (ADE) when culture results are available. Unfortunately, ADE is not uniform with de-escalation in the absence of positive cultures being particularly challenging. The purpose of this study was to evaluate rates of antibiotic de-escalation in an ICU population and assess clinical outcomes associated with ADE in patients with negative clinical cultures.
Methods:
This single-center, retrospective, cohort study evaluated ICU patients who received broad-spectrum antibiotics, defined as a pivotal beta lactam covering for Pseudomonas aeruginosa and a companion agent covering for MRSA or double covering for Pseudomonas, from June 2017 to August 2019. Appropriate de-escalation was defined in this study as medications that were either discontinued or narrowed in spectrum within 72 hours of initiation. Patients had to receive at least 5 days of antibiotic therapy and have negative cultures to be included. Patients with febrile neutropenia, cystic fibrosis, and extended prophylaxis were excluded. The primary outcome was rate of pivotal antibiotic de-escalation. Secondary outcomes included mortality, rates of antimicrobial escalation, AKI incidence, new hospital acquired infections, and lengths of stay in patients who underwent de-escalation compared with those who did not.
Results:
Of the 173 patients included in this study, only 38 (22%) patients had their pivotal antibiotics de-escalated within 72 hours. Incidence of companion antibiotic de-escalation at 72 hours was much higher with 82 (47.4%) patients. Patients who underwent de-escalation had significantly shorter durations of antibiotic therapy (p=0.033), lengths of stay (p=< 0.001) and incidence of AKI (p=0.037), but no statistical difference in mortality or development of resistance was found.
Conclusions:
While this study shows that de-escalation is feasible without worsening of outcomes, further study is necessary for its impact on resistance development and other adverse events in culture negative patients.