|
1
|
Routsi C, Gkoufa A, Arvaniti K, Kokkoris S, Tourtoglou A, Theodorou V, Vemvetsou A, Kassianidis G, Amerikanou A, Paramythiotou E, Potamianou E, Ntorlis K, Kanavou A, Nakos G, Hassou E, Antoniadou H, Karaiskos I, Prekates A, Armaganidis A, Pnevmatikos I, Kyprianou M, Zakynthinos S, Poulakou G, Giamarellou H. De-escalation of antimicrobial therapy in ICU settings with high prevalence of multidrug-resistant bacteria: a multicentre prospective observational cohort study in patients with sepsis or septic shock. J Antimicrob Chemother 2021; 75:3665-3674. [PMID: 32865203 DOI: 10.1093/jac/dkaa375] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 08/03/2020] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND De-escalation of empirical antimicrobial therapy, a key component of antibiotic stewardship, is considered difficult in ICUs with high rates of antimicrobial resistance. OBJECTIVES To assess the feasibility and the impact of antimicrobial de-escalation in ICUs with high rates of antimicrobial resistance. METHODS Multicentre, prospective, observational study in septic patients with documented infections. Patients in whom de-escalation was applied were compared with patients without de-escalation by the use of a propensity score matching by SOFA score on the day of de-escalation initiation. RESULTS A total of 262 patients (mean age 62.2 ± 15.1 years) were included. Antibiotic-resistant pathogens comprised 62.9%, classified as MDR (12.5%), extensively drug-resistant (49%) and pandrug-resistant (1.2%). In 97 (37%) patients de-escalation was judged not feasible in view of the antibiotic susceptibility results. Of the remaining 165 patients, judged as patients with de-escalation possibility, de-escalation was applied in 60 (22.9%). These were matched to an equal number of patients without de-escalation. In this subset of 120 patients, de-escalation compared with no de-escalation was associated with lower all-cause 28 day mortality (13.3% versus 36.7%, OR 0.27, 95% CI 0.11-0.66, P = 0.006); ICU and hospital mortality were also lower. De-escalation was associated with a subsequent collateral decrease in the SOFA score. Cox multivariate regression analysis revealed de-escalation as a significant factor for 28 day survival (HR 0.31, 95% CI 0.14-0.70, P = 0.005). CONCLUSIONS In ICUs with high levels of antimicrobial resistance, feasibility of antimicrobial de-escalation was limited because of the multi-resistant pathogens isolated. However, when de-escalation was feasible and applied, it was associated with lower mortality.
Collapse
Affiliation(s)
- Christina Routsi
- 1st Department of Intensive Care, School of Medicine, National and Kapodistrian University of Athens, 'Evangelismos' Hospital, Athens, Greece.,Hellenic Society of Antimicrobial Chemotherapy, Greece
| | | | - Kostoula Arvaniti
- Department of Intensive Care, 'Papageorgiou' Hospital, Thessaloniki, Greece
| | - Stelios Kokkoris
- 1st Department of Intensive Care, School of Medicine, National and Kapodistrian University of Athens, 'Evangelismos' Hospital, Athens, Greece
| | | | - Vassiliki Theodorou
- Department of Intensive Care, Democritus University of Thrace, Alexandroupolis University Hospital, Alexandroupolis, Greece
| | - Anna Vemvetsou
- Department of Intensive Care, 'Papageorgiou' Hospital, Thessaloniki, Greece
| | | | | | - Elisabeth Paramythiotou
- 2nd Department of Intensive Care, School of Medicine, National and Kapodistrian University of Athens, 'Attikon' Hospital, Athens, Greece
| | - Efstathia Potamianou
- 1st Department of Respiratory Medicine, Intensive Care Unit, School of Medicine, National and Kapodistrian University of Athens, 'Sotiria' Hospital, Athens, Greece
| | - Kyriakos Ntorlis
- Department of Intensive Care, 'Konstantopouleio' Hospital, Athens, Greece
| | - Angeliki Kanavou
- Department of Intensive Care, 'Thriassio' Hospital, Elefsina, Greece
| | - Georgios Nakos
- Department of Intensive Care, 'Henry Dunant' Hospital Center, Athens, Greece
| | - Eleftheria Hassou
- Department of Intensive Care, 'Gennimatas' Hospital, Thessaloniki, Greece
| | - Helen Antoniadou
- Department of Intensive Care, 'Gennimatas' Hospital, Thessaloniki, Greece
| | - Ilias Karaiskos
- Hellenic Society of Antimicrobial Chemotherapy, Greece.,Hygeia General Hospital, Athens, Greece
| | | | - Apostolos Armaganidis
- 2nd Department of Intensive Care, School of Medicine, National and Kapodistrian University of Athens, 'Attikon' Hospital, Athens, Greece
| | - Ioannis Pnevmatikos
- Department of Intensive Care, Democritus University of Thrace, Alexandroupolis University Hospital, Alexandroupolis, Greece
| | | | - Spyros Zakynthinos
- 1st Department of Intensive Care, School of Medicine, National and Kapodistrian University of Athens, 'Evangelismos' Hospital, Athens, Greece
| | - Garyfallia Poulakou
- Hellenic Society of Antimicrobial Chemotherapy, Greece.,School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Helen Giamarellou
- Hellenic Society of Antimicrobial Chemotherapy, Greece.,Hygeia General Hospital, Athens, Greece
| |
Collapse
|