» Articles » PMID: 39657050

Epidemiology and Outcomes of Antibiotic De-escalation in Patients With Suspected Sepsis in US Hospitals

Abstract

Background: Little is known about the frequency, hospital-level variation, predictors, and outcomes of antibiotic de-escalation in suspected sepsis.

Methods: We retrospectively analyzed adults admitted to 236 US hospitals from 2017-2021 with suspected sepsis (defined by blood culture draw, lactate measurement, and intravenous antibiotic administration) who were initially treated with ≥2 days of anti-methicillin-resistant Staphylococcus aureus (MRSA) and anti-pseudomonal antibiotics but had no resistant organisms that required these agents identified through hospital day 4. De-escalation was defined as stopping anti-MRSA and anti-pseudomonal antibiotics or switching to narrower antibiotics by day 4. We created a propensity score for de-escalation using 82 hospital and clinical variables; matched de-escalated to non-de-escalated patients; and assessed associations between de-escalation and outcomes.

Results: Among 124 577 patients, antibiotics were de-escalated in 36 806 (29.5%): narrowing in 27 177 (21.8%), cessation in 9629 (7.7%). De-escalation rates varied between hospitals (median, 29.4%; interquartile range, 21.3%-38.0%). Predictors of de-escalation included less severe disease on day 3-4, positive cultures for nonresistant organisms, and negative/absent MRSA nasal swabs. De-escalation was more common in medium, large, and teaching hospitals in the Northeast and Midwest. De-escalation was associated with lower adjusted risks for acute kidney injury (AKI) (odds ratio [OR], 0.80; 95% confidence interval [CI], .76-.84), intensive-care unit (ICU) admission after day 4 (OR, 0.59; 95% CI, .52-.66), and in-hospital mortality (OR, 0.92; 95% CI, .86-.996).

Conclusions: Antibiotic de-escalation in suspected sepsis is infrequent, variable across hospitals, linked with clinical and microbiologic factors, and associated with lower risk for AKI, ICU admission, and in-hospital mortality.

References
1.
Guo Y, Gao W, Yang H, Ma C, Sui S . De-escalation of empiric antibiotics in patients with severe sepsis or septic shock: A meta-analysis. Heart Lung. 2016; 45(5):454-9. DOI: 10.1016/j.hrtlng.2016.06.001. View

2.
Singer M, Deutschman C, Seymour C, Shankar-Hari M, Annane D, Bauer M . The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016; 315(8):801-10. PMC: 4968574. DOI: 10.1001/jama.2016.0287. View

3.
Goodman K, Baghdadi J, Magder L, Heil E, Sutherland M, Dillon R . Patterns, Predictors, and Intercenter Variability in Empiric Gram-Negative Antibiotic Use Across 928 United States Hospitals. Clin Infect Dis. 2022; 76(3):e1224-e1235. PMC: 9907550. DOI: 10.1093/cid/ciac504. View

4.
Kollef M, Shorr A, Bassetti M, Timsit J, Micek S, Michelson A . Timing of antibiotic therapy in the ICU. Crit Care. 2021; 25(1):360. PMC: 8518273. DOI: 10.1186/s13054-021-03787-z. View

5.
Morel J, Casoetto J, Jospe R, Aubert G, Terrana R, Dumont A . De-escalation as part of a global strategy of empiric antibiotherapy management. A retrospective study in a medico-surgical intensive care unit. Crit Care. 2010; 14(6):R225. PMC: 3219998. DOI: 10.1186/cc9373. View