Impact of Extended and Restricted Antibiotic Deescalation on Mortality.

Hwei Lin Teh,Chee Loon Leong,Sarimah Abdullah,Rahela Ambaras Khan,Anis Kausar Ghazali,Anitha Ramadas

doi:10.3390/antibiotics11010022

Hwei Lin Teh, Chee Loon Leong + Show 4 more

Open Access

https://doi.org/10.3390/antibiotics11010022

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Abstract

Background: More data are needed about the safety of antibiotic de-escalation in specific clinical situations as a strategy to reduce exposure to broad-spectrum antibiotics. This study aims to compare the survival curve of patient de-escalated (early or late) against those not de-escalated on antibiotics, to determine the association of patient related, clinical related, and pressure sore/device related characteristics on all-cause 30-day mortality and determine the impact of early and late antibiotic de-escalation on 30-day all-cause mortality. Methods: This is a retrospective cohort study on patients in medical ward Hospital Kuala Lumpur, admitted between January 2016 and June 2019. A Kaplan–Meier survival curve and Fleming–Harrington test were used to compare the overall survival rates between early, late, and those not de-escalated on antibiotics while multivariable Cox proportional hazards regression was used to determine prognostic factors associated with mortality and the impact of de-escalation on 30-day all-cause mortality. Results: Overall mortality rates were not significantly different when patients were not de-escalated on extended or restricted antibiotics, compared to those de-escalated early or later (p = 0.760). Variables associated with 30-day all-cause mortality were a Sequential Organ Function Assessment (SOFA) score on the day of antimicrobial stewardship (AMS) intervention and Charlson’s comorbidity score (CCS). After controlling for confounders, early and late antibiotics were not associated with an increased risk of mortality. Conclusion: The results of this study reinforce that restricted or extended antibiotic de-escalation in patients does not significantly affect 30-day all-cause mortality compared to continuation with extended and restricted antibiotics.

Highlights

Antibiotic overconsumption and inappropriate antibiotic use remain the key drivers of bacterial resistance, with 30–50% of prescribed antibiotics being used inappropriately in hospital settings [1,2]
Studies have shown that one of the main barriers is uncertainty regarding the safety of de-escalation, despite it being a standard of care among practicing physicians, especially in negative cultures [6,7]
The safety of de-escalation has been well established in various international studies, there is currently only one study in Malaysia on antibiotic de-escalation, which focuses on a single infection of ventilatorassociated pneumonia in an intensive care unit [8]

Summary

Introduction

Antibiotic overconsumption and inappropriate antibiotic use remain the key drivers of bacterial resistance, with 30–50% of prescribed antibiotics being used inappropriately in hospital settings [1,2]. The antimicrobial stewardship program strongly recommends de-escalation in order to promote judicious antimicrobial use and limit costs, adverse events, and the development of antibiotic resistance [5]. It is less commonly practiced than desired. We hypothesized that there would be no difference in survival probabilities between patients not de-escalated on antibiotics and those who had early or late deescalation, while the prognostic factors for all-cause 30-day mortality of patients with suspected bacterial infection initiated with extended or restricted antibiotics would be patient-related, clinically related, and pressure sore/device-related characteristics. We hypothesized that there would be no significant detrimental impact of early and late de-escalation on all-cause 30-day mortality

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