Effect of Broad-Spectrum Antibiotic De-escalation on Critically Ill Patient Outcomes: A Retrospective Cohort Study

PURPOSE

Antibiotic de-escalation (ADE) in critically ill patients is controversial. Previous studies mainly focused on mortality; however, data are lacking about superinfection. Therefore, we aimed to identify the impact of ADE versus continuation of therapy on superinfections rate and other outcomes in critically ill patients.

METHODS

This was a two-center retrospective cohort study of adults initiated on broad-spectrum antibiotics in the intensive care unit (ICU) for ≥ 48 h. The primary outcome was the superinfection rate. Secondary outcomes included 30-day infection recurrence, ICU and hospital length of stay, and mortality.

RESULTS

250 patients were included, 125 in each group (ADE group and continuation group). Broad spectrum antibiotic discontinuation occurred at a mean of 7.2 ± 5.2 days in the ADE arm vs. 10.3 ± 7.7 in the continuation arm (P value = 0.001). Superinfection was numerically lower in the ADE group (6.4% vs. 10.4%; P = 0.254), but the difference was not significant. Additionally, the ADE group had shorter days to infection recurrence (P = 0.045) but a longer hospital stay (26 (14-46) vs. 21 (10-36) days; P = 0.016) and a longer ICU stay (14 (6-23) vs. 8 (4-16) days; P = 0.002).

CONCLUSION

No significant differences were found in superinfection rates among ICU patients whose broad-spectrum antibiotics were de-escalated versus patients whose antibiotics were continued. Future research into the association between rapid diagnostics with antibiotic de-escalation in the setting of high resistance is warranted.

Continuation Versus De-escalation of Broad-Spectrum Antibiotic Therapy in Critically Ill COVID-19 Patients

Background

Antibiotic de-escalation (ADE) is a stewardship initiative that aims to reduce exposure to antimicrobials, thus limiting their unwanted effect, including antimicrobial resistance. Our study aims to describe the impact of ADE compared with the continuation of therapy on the outcome of critically ill coronavirus disease 2019 (COVID-19) patients.

Material and Methods

A single-center retrospective study included critically ill COVID-19 adult patients admitted between January 1, 2019 and August 31, 2021, and started on broad-spectrum antibiotics. The primary outcome was intensive care unit (ICU) mortality. In addition, other clinical outcomes were evaluated, including ICU readmissions, length of stay, and superinfection.

Results

The study included 73 patients with a mean age of 61.0 ± 19.4, and ADE was performed in 10 (13.6%) of these. In the ADE group, 8/10 (80%) cultures were positive. ICU mortality was not statistically different between ADE and continuation of therapy groups (60 vs. 41.3%, respectively, P = 0.317). Superinfection occurred in 4 (5.4%) patients. Hospital mortality, length of stay, and ICU readmission rates did not differ significantly between groups.

Conclusion

De-escalation of broad-spectrum antibiotics in critically ill covid-19 patients was not associated with higher mortality. A larger cohort is needed to confirm these findings.

Supplementary Information

The online version contains supplementary material available at 10.1007/s44229-023-00027-0.