Abstract
BackgroundAntibiotics are commonly administered to hospitalized patients with infiltrates for possible bacterial pneumonia, often leading to unnecessary treatment and increasing the risk for resistance emergence. Therefore, we performed a study to determine if an enhanced antibiotic de-escalation practice could improve antibiotic utilization in mechanically ventilated patients with suspected pneumonia cared for in an academic closed intensive care unit (ICU).MethodsThis was a prospective cross-over trial comparing routine antibiotic management (RAM) and enhanced antimicrobial de-escalation (EAD) performed within two medical ICUs (total 34 beds) at Barnes-Jewish Hospital, an academic referral center. Patients in the EAD group had their antibiotic orders and microbiology results reviewed daily by a dedicated team comprised of a second-year critical care fellow, an ICU attending physician and an ICU pharmacist. Antibiotic de-escalation recommendations were made when appropriate based on microbiologic test results and clinical response to therapy.ResultsThere were 283 patients evaluable, with suspected pneumonia requiring mechanical ventilation: 139 (49.1%) patients in the RAM group and 144 (50.9%) in the EAD group. Early treatment failure based on clinical deterioration occurred in 33 (23.7%) and 40 (27.8%) patients, respectively (P = 0.438). In the remaining patients, antimicrobial de-escalation occurred in 70 (66.0%) and 70 (67.3%), respectively (P = 0.845). There was no difference between groups in total antibiotic days ((median (interquartile range)) 7.0 days (4.0, 9.0) versus 7.0 days (4.0, 8.8) (P = 0.616)); hospital mortality (25.2% versus 35.4% (P = 0.061)); or hospital duration (12.0 days (6.0, 20.0) versus 11.0 days (6.0, 22.0) (P = 0.918).ConclusionsThe addition of an EAD program to a high-intensity daytime staffing model already practicing a high-level of antibiotic stewardship in an academic ICU was not associated with greater antibiotic de-escalation or a reduction in the overall duration of antibiotic therapy.Trial registrationClinicalTrials.gov, NCT02685930. Registered on 26 January 2016.
Highlights
Antibiotics are commonly administered to hospitalized patients with infiltrates for possible bacterial pneumonia, often leading to unnecessary treatment and increasing the risk for resistance emergence
The practice of antibiotic de-escalation has emerged as an antibiotic decisionmaking strategy in the intensive care unit (ICU) balancing the need for IAAT, in order to improve patient outcomes, with the need for avoidance of unnecessary antibiotics so as to reduce resistance emergence [10]
Given the importance of balancing IAAT with the avoidance of unnecessary antibiotic exposure, we performed a clinical trial with the goal of determining whether an enhanced antimicrobial de-escalation (EAD) practice could improve antibiotic utilization and outcomes in mechanically ventilated patients with suspected pneumonia
Summary
Antibiotics are commonly administered to hospitalized patients with infiltrates for possible bacterial pneumonia, often leading to unnecessary treatment and increasing the risk for resistance emergence. We performed a study to determine if an enhanced antibiotic de-escalation practice could improve antibiotic utilization in mechanically ventilated patients with suspected pneumonia cared for in an academic closed intensive care unit (ICU). The practice of antibiotic de-escalation has emerged as an antibiotic decisionmaking strategy in the ICU balancing the need for IAAT, in order to improve patient outcomes, with the need for avoidance of unnecessary antibiotics so as to reduce resistance emergence [10]. Given the importance of balancing IAAT with the avoidance of unnecessary antibiotic exposure, we performed a clinical trial with the goal of determining whether an enhanced antimicrobial de-escalation (EAD) practice could improve antibiotic utilization and outcomes in mechanically ventilated patients with suspected pneumonia. We wanted to determine whether a practice of EAD impacted other outcomes including mortality and lengths of stay
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