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Antibiotic de-escalation in the ICU: how is it best done?

Garnacho-Montero, Josea,b,c; Escoresca-Ortega, Anaa; Fernández-Delgado, Esperanzaa

Current Opinion in Infectious Diseases: April 2015 - Volume 28 - Issue 2 - p 193–198
doi: 10.1097/QCO.0000000000000141
RESPIRATORY INFECTIONS: Edited by Michael S. Niederman
Editor's Choice

Purpose of review An antimicrobial policy consisting of the initial use of wide-spectrum antimicrobials followed by a reassessment of treatment when culture results are available is termed de-escalation therapy. Our aim is to examine the safety and feasibility of antibiotic de-escalation in critically ill patients providing practical tips about how to accomplish this strategy in the critical care setting.

Recent findings Numerous studies have assessed the rates of de-escalation therapy (range from 10 to 60%) in patients with severe sepsis or ventilator-associated pneumonia as well as the factors associated with de-escalation. De-escalation generally refers to a reduction in the spectrum of administered antibiotics through the discontinuation of antibiotics or switching to an agent with a narrower spectrum. Diverse studies have identified the adequacy of initial therapy as a factor independently associated with de-escalation. Negative impact on different outcome measures has not been reported in the observational studies. Two randomized clinical trials have evaluated this strategy in patients with ventilator-associated pneumonia or severe sepsis. These trials alert us about the possibility that this strategy may be linked to a higher rate of reinfections but without an impact on mortality.

Summary Antibiotic de-escalation is a well tolerated management strategy in critically ill patients but unfortunately is not widely adopted.

aCritical Care and Emergency Department, Intensive Care Unit, Virgen del Rocío University Hospital

bInstituto de Biomedicina de Sevilla (IBIS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla

cSpanish Network for Research in Infectious Disease (REIPI), Virgen del Rocío University Hospital, Sevilla, Spain

Correspondence to Jose Garnacho-Montero, MD, Critical Care and Emergency Department, Intensive Care Unit, Virgen del Rocío University Hospital, Avd Manuel Siurot, s/n, 41013, Sevilla, Spain. E-mail:

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