Purpose of review: To describe the use of a 'de-escalation' strategy to deliver appropriate empiric therapy for ventilator-associated pneumonia, without the overuse of antibiotics.
Recent findings: Initial empiric therapy can be appropriate in 80-90% of ventilator-associated pneumonia patients, if it is selected on the basis of local microbiologic data or individual patient surveillance cultures. Following initial empiric therapy, de-escalation means using microbiologic and clinical data to change from an initial broad-spectrum, multidrug empiric therapy regimen to a therapy with fewer antibiotics and agents of narrower spectrum. In spite of early success with this approach there is an opportunity to de-escalate more often, particularly in patients with negative pretherapy cultures, and in those whose cultures show multidrug-resistant organisms, including Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus. In addition, it is possible to reduce the total duration of therapy, particularly when the initial therapy is accurate. When de-escalation has been employed, it has led to less antibiotic usage, shorter durations of therapy, fewer episodes of secondary pneumonia and reduced mortality, without increasing the frequency of antibiotic resistance.
Summary: De-escalation is a promising strategy for optimizing the responsible use of antibiotics while allowing the delivery of prompt and appropriate empiric therapy of ventilator-associated pneumonia.