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De-escalation not detrimental to patients with bacteremia
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Antibiotic de-escalation is not detrimental to clinical outcomes in patients with monomicrobial bacteremia due to Enterobacteriaceae, according to study findings from Spain.
Researchers said the findings “may be useful for antibiotic stewardship activities.”
“Patients with sepsis are frequently treated empirically with broad-spectrum drugs because the early administration of active drugs has been associated with improved outcome, particularly in the presence of septic shock. This can lead to overuse of these drugs, which is usually considered to be one of the contributing factors for the spread of multidrug-resistant bacteria,” Zaira R. Palacios-Baena, MD, PhD, ID specialist in the department of microbiology and preventive medicine at University Hospital Virgen Macarena in Seville, Spain, and colleagues wrote.
Although antimicrobial stewardship interventions include strategies for de-escalation to narrower-spectrum drugs, the researchers said it is performed “less frequently than desirable,” with prescriber uncertainty — perhaps due to a lack of evidence — being a main barrier.
For their study, Palacios-Baena and colleagues conducted a post-hoc analysis of data from patients with bloodstream infections, which they said present “an ideal model for de-escalation, since etiology and susceptibility are known, and a more specialized evaluation of patients is possible.”
“It is important to note that we only included non-neutropenic, adult patients with monomicrobial bacteremia due to Enterobacteriaceae who received early active empirical monotherapy with antipseudomonal beta-lactams or ertapenem,” they wrote.
The original prospective, multicenter study was conducted between January 2011 and December 2013. Patients were initially treated with either ertapenem or antipseudomonal beta-lactams at 13 university hospitals in Spain. Palacios-Baena and colleagues analyzed factors associated with early de-escalation, the impact of early de-escalation and late de-escalation on 30-day all-cause mortality, failure at end of treatment and length of hospital stay.
The study included 516 patients, with early de-escalation performed for 46% (n = 241), late de-escalation for 18% (n = 98) and no de-escalation for 35% (n = 180). Multidrug-resistant isolates (OR = 0.50; 95% CI, 0.30-0.83) and nosocomial infections empirically treated with imipenem or meropenem (OR = 0.35; 95% CI, 0.14-0.87) were each independently associated with a lower probability of early de-escalation, according to Palacios-Baena and colleagues.
The researchers did not observe an increased risk for mortality associated with early de-escalation, after controlling for confounders. They reported that late de-escalation also was not associated with mortality, and that de-escalation overall was not associated with clinical failure or length of hospital stay.
“The results of this study reinforce the fact that antibiotic de-escalation in patients with monomicrobial bacteremia due to Enterobacteriaceae does not have a detrimental impact on outcome, 30-day all-cause mortality, failure, or length of hospital stay when compared with continuation with broad-spectrum antibiotics,” Palacios-Baena and colleagues wrote. – by Marley Ghizzone
Disclosures: Palacios-Baena reports receiving personal fees from Gilead Sciences outside of the study. Please see the study for all other authors’ relevant financial disclosures.
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