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De-escalation of empiric antibiotic therapy in sepsis - an indian observational study
Intensive Care Medicine Experimentalvolume 3, Article number: A405 (2015)
The guidelines for an appropriate use of antibiotic therapy recommend de-escalation as soon as the culture sensitivity results are available.There was a great need to study the frequency of de-escalation, no change and escalation of antibiotics and its impact in septic patients in an Indian ICU setting in view of rising burden of drug resistance and health care cost.
To determine the rate of de-escalation of the empiric antimicrobial treatment in ICU patients admitted with sepsis. The characteristics of antimicrobial treatment associated with de-escalation & its impact on ICU length of stay, hospital length of stay (LOS) and 30 day mortality were determined.
We carried out a prospective observational study enrolling patients admitted to the ICU with sepsis from 01/02/2014 to 01/03/2015. Both the medical and surgical units of the ICU were included. "No change" was defined as when empiric therapy was maintained without modification, "Escalation of therapy" was defined when there’s a switch to or addition of an antibiotic with a broader spectrum, and "De-escalation" when there’s a switch to or interruption of a drug class resulting in a less broad spectrum of coverage. If antimicrobial change consisted of escalation and de-escalation (i.e. switch to or addition of an antibiotic with a broader spectrum but also withdrawal of another antibiotic), the patient was assigned to "escalation group" for statistical analysis.
The total number of patients enrolled were 315 out of which 17 patients were excluded due to death before culture results were available. The characteristics observed among the therapeutic strategy groups were seen in tables 1, 2.
The most common antibiotic after de-escalation& antibiotic in No Change group was Betalactam + beta lactamase inhibitor.
The statistically significant factors which increased the 30 day mortality are Escalation of antibiotics, Increased ICU LOS, Increased APACHE II and SOFA scores at admission, medical patients, vasopressor requirement, lung as the source of infection, Infection with MDR organisms.
The statistically significant factors which increased the ICU LOS are use of vasopressors, Comorbidities, APACHE II at admission, SOFA at admission, MDR organisms, escalation of antibiotic.
Escalation of antibiotics resulted in statistically significant increase in the mortality and increased length of stay in the ICU and hospital. No significant differences were observed with respect to ICU length of stay, Hospital length of stay and 30 day mortality among No Change & De Escalation groups.
Garnacho-Montero J, Gutiérrez-Pizarraya A, Escoresca-Ortega A, Corcia-Palomo Y, Fernández-Delgado E, Herrera-Melero I, et al: De-escalation of empirical therapy is associated with lower mortality in patients with severe sepsis and septic shock. Intensive Care Med. 2014, 40: 32-40. 10.1007/s00134-013-3077-7.