Journal Article

Enhanced antimicrobial de-escalation for pneumonia in mechanically ventilated patients: a cross-over study

Juang, Paul, Trupka, Tracy, Micek, Scott T., Fisher, Kristen, Kollef, Marin H.

2017

Overview

Background 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. 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). Methods This 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. Results There 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). Conclusions The 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 registration ClinicalTrials.gov, NCT02685930 . Registered on 26 January 2016.

• Publisher: BioMed Central,BioMed Central Ltd,Springer Nature B.V,BMC
• Subject: Academic Medical Centers - organization & administration / Adults / Aged / Anti-Bacterial Agents - analysis / Anti-Bacterial Agents - pharmacology / Anti-Bacterial Agents - therapeutic use / Antibiotics / Antimicrobial agents / Artificial respiration / Bacteria / Bacterial pneumonia / Carbapenems - analysis / Carbapenems - pharmacology / Carbapenems - therapeutic use / Cefepime / Ceftriaxone - analysis / Ceftriaxone - pharmacology / Ceftriaxone - therapeutic use / Cephalosporins - analysis / Cephalosporins - pharmacology / Cephalosporins - therapeutic use / Clinical decision making / Clinical deterioration / Clinical outcomes / Critical care / Critical Care Medicine / Cross-Over Studies / De-escalation / Decision making / Dosage and administration / Drug resistance / Drug therapy / Emergency Medicine / Female / Health aspects / Hospital Mortality / Hospital patients / Hospitals / Humans / Infections / Infectious diseases / Intensive / Intensive care / Intensive Care Units - organization & administration / Male / Mechanical ventilation / Medicine / Medicine & Public Health / Middle Aged / Monobactams - analysis / Monobactams - pharmacology / Monobactams - therapeutic use / Mortality / Pathogens / Pharmacists / Pneumonia / Pneumonia - drug therapy / Pneumonia, Ventilator-Associated - drug therapy / Prospective Studies / Quinolones - analysis / Quinolones - pharmacology / Quinolones - therapeutic use / Respiration, Artificial - adverse effects / Sepsis / Statistics, Nonparametric / Teams