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Does Antibiotic De-escalation for Nosocomial Pneumonia Impact Intensive Care Unit Length of Stay?

Knaak, Elizabeth PharmD*; Cavalieri, Stephen J. PhD; Elsasser, Gary N. PharmD*†; Preheim, Laurel C. MD; Gonitzke, Alyssa PharmD*; Destache, Christopher J. PharmD*†

Infectious Diseases in Clinical Practice: May 2013 - Volume 21 - Issue 3 - p 172–176
doi: 10.1097/IPC.0b013e318279ee87
Original Articles

Background Hospital-acquired pneumonia (HAP), ventilator-associated pneumonia (VAP), and health care–associated pneumonia (HCAP) are associated with substantial morbidity, mortality, and costs in the intensive care unit (ICU). The impact of antibiotic de-escalation on resource utilization, namely, length of stay (LOS) and cost of hospitalization, was investigated.

Methods A retrospective chart review was conducted from ICU admission of adult patients with a presumptive diagnosis of HAP, VAP, or HCAP in the 2009–2010 year. American Thoracic Society/Infectious Disease Society of America definitions for HAP, VAP, or HCAP were used. Eligible patients had blood and/or respiratory cultures collected before institution of empiric antibiotics. De-escalation required discontinuation of one or more empiric agent or change to narrower-spectrum antibiotic. The primary end point was the effect of antibiotic de-escalation on ICU LOS.

Results One hundred thirteen patients, representing 117 cases of HCAP, HAP, and VAP, met eligibility criteria. De-escalation was performed in 73 (62%) of pneumonias. De-escalated patients were more likely to be older (65.1 [SD, 16.8] vs 57.6 [SD, 19] years, P < 0.05) and have cardiovascular disease (37% vs 14%, P < 0.01). Intensive care unit LOS (9.3 [SD, 11.6] vs 13 [SD, 9.7] days, P = 0.069) was not significantly different; however, a significant difference in hospitalization costs ($38,016 [SD, 43,010] vs $55,217 [SD, 47,642], P < 0.05) was found between the 2 groups. In-hospital mortality was significantly lower in de-escalated pneumonias (15% vs 39%, P < 0.01).

Conclusions Although ICU LOS was not significantly different in this study, de-escalation was associated with significant reduction in resource utilization. In ICU patients with HCAP, HAP, or VAP, de-escalation affords an opportunity to improve antimicrobial stewardship and decrease resource utilization at no detriment to clinical outcome.

From the *Creighton University Schools of Pharmacy & Health Professions and †Medicine, Omaha, NE.

Correspondence to: Christopher J. Destache, PharmD, Creighton University School of Pharmacy & Health Professions, Hixson-Lied Science Bldg, Room 114, 2500 California Plaza, Omaha, NE 68178. E-mail:

This study was presented in part as an abstract to the 51st ICAAC meeting, Chicago, IL, September 2011.

The authors have no funding or conflicts of interest to disclose.

© 2013 Lippincott Williams & Wilkins, Inc.