Scrutinising the Paradigm of Antibiotic De-Escalation

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One of the key elements within antimicrobial stewardship and treatment paradigms for serious sepsis is de-escalation of antibiotic treatment. Antibiotic de-escalation describes a mechanism whereby the provision of effective initial antibiotic treatment is achieved while avoiding unnecessary antibiotic use that would promote the development of resistance. Basically it means that empirical antibiotics are stopped stopped or reduced in number and/or narrowed in spectrum on the basis of culture results. The recommendation to do so is mainly supported by observational studies only.

This makes the publication of Leone at al. in Intensive Care Medicine of last month remarkable as they are the first to present a multi-center, non-blinded, randomised non-inferiority trial on de-escalation versus continuation of empirical antimicrobial treatment in severe Sepsis.

After screening they included 120 patients of which 60 were assigned to continuation of appropriate empirical antimicrobial treatment and the other 60 to de-escalation. As a result de-escalation did not improve ICU length of stay (primary endpoint). De-escalation was associated though with an increased number of super infections (secondary endpoint), but did not affect mortality (secondary endpoint).

Despite the studies limitations (relatively small population, lack of blind treatment and some other minor details) these results come surprisingly and leave us with the conclusion:

De-escalation of antimicrobial treatment might remain standard of care at this stage but should be questioned if this is true in general.
Leone M et al. Intensive Care Med (2014) 40:1399–1408

Masterton RG, Crit Care Clin (2011), Vol 27

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