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Characteristics and outcomes of anti-infective de-escalation during health care-associated intra-abdominal infections
- Source :
- Critical Care
- Publication Year :
- 2016
- Publisher :
- Springer Science and Business Media LLC, 2016.
-
Abstract
- Background De-escalation is strongly recommended for antibiotic stewardship. No studies have addressed this issue in the context of health care-associated intra-abdominal infections (HCIAI). We analyzed the factors that could interfere with this process and their clinical consequences in intensive care unit (ICU) patients with HCIAI. Methods All consecutive patients admitted for the management of HCIAI who survived more than 3 days following their diagnosis, who remained in the ICU for more than 3 days, and who did not undergo early reoperation during the first 3 days were analyzed prospectively in an observational, single-center study in a tertiary care university hospital. Results Overall, 311 patients with HCIAI were admitted to the ICU. De-escalation was applied in 110 patients (53 %), and no de-escalation was reported in 96 patients (47 %) (escalation in 65 [32 %] and unchanged regimen in 31 [15 %]). Lower proportions of Enterococcus faecium, nonfermenting Gram-negative bacilli (NFGNB), and multidrug-resistant (MDR) strains were cultured in the de-escalation group. No clinical difference was observed at day 7 between patients who were de-escalated and those who were not. Determinants of de-escalation in multivariate analysis were adequate empiric therapy (OR 9.60, 95 % CI 4.02–22.97) and empiric use of vancomycin (OR 3.39, 95 % CI 1.46–7.87), carbapenems (OR 2.64, 95 % CI 1.01–6.91), and aminoglycosides (OR 2.31 95 % CI 1.08–4.94). The presence of NFGNB (OR 0.28, 95 % CI 0.09–0.89) and the presence of MDR bacteria (OR 0.21, 95 % CI 0.09–0.52) were risk factors for non-de-escalation. De-escalation did not change the overall duration of therapy. The risk factors for death at day 28 were presence of fungi (HR 2.64, 95 % CI 1.34–5.17), Sequential Organ Failure Assessment score on admission (HR 1.29, 95 % CI 1.16–1.42), and age (HR 1.03, 95 % CI 1.01–1.05). The survival rate expressed by a Kaplan-Meier curve was similar between groups (log-rank test p value 0.176). Conclusions De-escalation is a feasible option in patients with polymicrobial infections such as HCIAI, but MDR organisms and NFGNB limit its implementation.
- Subjects :
- Male
medicine.medical_specialty
Time Factors
Critical Care
Multidrug-resistant bacteria
Peritonitis
Context (language use)
Critical Care and Intensive Care Medicine
law.invention
03 medical and health sciences
0302 clinical medicine
Vancomycin
law
Internal medicine
Humans
Medicine
030212 general & internal medicine
Survival rate
Aged
Health care-associated intra-abdominal infections
Cross Infection
business.industry
Research
Drug Resistance, Microbial
030208 emergency & critical care medicine
Antibiotic therapy
Middle Aged
medicine.disease
Intensive care unit
De-escalation
Anti-Bacterial Agents
Surgery
Intensive Care Units
Regimen
Treatment Outcome
Intraabdominal Infections
Female
business
Empiric therapy
medicine.drug
Subjects
Details
- ISSN :
- 13648535
- Volume :
- 20
- Database :
- OpenAIRE
- Journal :
- Critical Care
- Accession number :
- edsair.doi.dedup.....6179d542c871fd675d5759764851bc06