De-escalation of empirical therapy is associated with lower mortality in patients with severe sepsis and septic shock

被引:317
作者
Garnacho-Montero, J. [1 ,2 ,3 ]
Gutierrez-Pizarraya, A. [3 ,4 ]
Escoresca-Ortega, A. [1 ]
Corcia-Palomo, Y. [1 ]
Fernandez-Delgado, Esperanza [1 ]
Herrera-Melero, I. [1 ]
Ortiz-Leyba, C. [1 ,2 ,3 ]
Marquez-Vacaro, J. A. [1 ]
机构
[1] Hosp Univ Virgen del Rocio, Unidad Clin Cuidados Crit & Urgencias, Seville, Spain
[2] Univ Seville, CSIC, Hosp Univ Virgen del Rocio, Inst Biomed Sevilla IBIS, Seville, Spain
[3] Hosp Univ Virgen del Rocio, Spanish Network Res Infect Dis REIPI, Seville, Spain
[4] Hosp Univ Virgen del Rocio, Unidad Clin Enfermedades Infecciosas Microbiol &, Seville, Spain
关键词
Critical care; Sepsis; Empirical therapy; Survival; De-escalation; Infectious diseases; INTENSIVE-CARE-UNIT; ANTIMICROBIAL THERAPY; ANTIBIOTIC-THERAPY; IMPACT; RESISTANCE; INFECTION; ICU; STRATEGIES; MANAGEMENT; INITIATION;
D O I
10.1007/s00134-013-3077-7
中图分类号
R4 [临床医学];
学科分类号
1002 ; 100602 ;
摘要
We set out to assess the safety and the impact on in-hospital and 90-day mortality of antibiotic de-escalation in patients admitted to the ICU with severe sepsis or septic shock. We carried out a prospective observational study enrolling patients admitted to the ICU with severe sepsis or septic shock. De-escalation was defined as discontinuation of an antimicrobial agent or change of antibiotic to one with a narrower spectrum once culture results were available. To control for confounding variables, we performed a conventional regression analysis and a propensity score (PS) adjusted-multivariable analysis. A total of 712 patients with severe sepsis or septic shock at ICU admission were treated empirically with broad-spectrum antibiotics. Of these, 628 were evaluated (84 died before cultures were available). De-escalation was applied in 219 patients (34.9 %). By multivariate analysis, factors independently associated with in-hospital mortality were septic shock, SOFA score the day of culture results, and inadequate empirical antimicrobial therapy, whereas de-escalation therapy was a protective factor [Odds-Ratio (OR) 0.58; 95 % confidence interval (CI) 0.36-0.93). Analysis of the 403 patients with adequate empirical therapy revealed that the factor associated with mortality was SOFA score on the day of culture results, whereas de-escalation therapy was a protective factor (OR 0.54; 95 % CI 0.33-0.89). The PS-adjusted logistic regression models confirmed that de-escalation therapy was a protective factor in both analyses. De-escalation therapy was also a protective factor for 90-day mortality. De-escalation therapy for severe sepsis and septic shock is a safe strategy associated with a lower mortality. Efforts to increase the frequency of this strategy are fully justified.
引用
收藏
页码:32 / 40
页数:9
相关论文
共 31 条
[1]   Antibiotic management of suspected nosocomial ICU-acquired infection: Does prolonged empiric therapy improve outcome? [J].
Aarts, Mary-Anne W. ;
Brun-Buisson, Christian ;
Cook, Deborah J. ;
Kumar, Anand ;
Opal, Steven ;
Rocker, Graeme ;
Smith, Terry ;
Vincent, Jean-Louis ;
Marshall, John C. .
INTENSIVE CARE MEDICINE, 2007, 33 (08) :1369-1378
[2]  
[Anonymous], COCHRANE DATABASE SY
[3]   The international sepsis forum consensus conference on definitions of infection in the intensive care unit [J].
Calandra, T ;
Cohen, J .
CRITICAL CARE MEDICINE, 2005, 33 (07) :1538-1548
[4]   Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008 [J].
Dellinger, R. Phillip ;
Levy, Mitchell M. ;
Carlet, Jean M. ;
Bion, Julian ;
Parker, Margaret M. ;
Jaeschke, Roman ;
Reinhart, Konrad ;
Angus, Derek C. ;
Brun-Buisson, Christian ;
Beale, Richard ;
Calandra, Thierty ;
Dhainaut, Jean-Francois ;
Gerlach, Herwig ;
Harvey, Maurene ;
Marini, John J. ;
Marshall, John ;
Ranieri, Marco ;
Ramsay, Graham ;
Sevransky, Jonathan ;
Thompson, B. Taylor ;
Townsend, Sean ;
Vender, Jeffrey S. ;
Zimmerman, Janice L. ;
Vincent, Jean-Louis .
CRITICAL CARE MEDICINE, 2008, 36 (01) :296-327
[5]  
DELLINGER RP, 2013, INTENS CARE MED, V39, P165, DOI DOI 10.1007/s00134-012-2769-8
[6]   Impact of adequate empirical antibiotic therapy on the outcome of patients admitted to the intensive care unit with sepsis [J].
Garnacho-Montero, J ;
Garcia-Garmendia, JL ;
Barrero-Almodovar, A ;
Jimenez-Jimenez, FJ ;
Perez-Paredes, C ;
Ortiz-Leyba, C .
CRITICAL CARE MEDICINE, 2003, 31 (12) :2742-2751
[7]   Mortality and morbidity attributable to inadequate empirical antimicrobial therapy in patients admitted to the ICU with sepsis:: a matched cohort study [J].
Garnacho-Montero, Jose ;
Ortiz-Leyba, Carlos ;
Herrera-Melero, Inmaculada ;
Aldabo-Pallas, Teresa ;
Cayuela-Dominguez, Aurelio ;
Marquez-Vacaro, Juan A. ;
Carbajal-Guerrero, Jesus ;
Garcia-Garmendia, Jose L. .
JOURNAL OF ANTIMICROBIAL CHEMOTHERAPY, 2008, 61 (02) :436-441
[8]   Propensity scores in intensive care and anaesthesiology literature: a systematic review [J].
Gayat, Etienne ;
Pirracchio, Romain ;
Resche-Rigon, Matthieu ;
Mebazaa, Alexandre ;
Mary, Jean-Yves ;
Porcher, Raphael .
INTENSIVE CARE MEDICINE, 2010, 36 (12) :1993-2003
[9]   Rational use of antibiotics in the intensive care unit: impact on microbial resistance and costs [J].
Geissler, A ;
Gerbeaux, P ;
Granier, I ;
Blanc, P ;
Facon, K ;
Durand-Gasselin, J .
INTENSIVE CARE MEDICINE, 2003, 29 (01) :49-54
[10]   De-escalation therapy rates are significantly higher by bronchoalveolar lavage than by tracheal aspirate [J].
Giantsou, Elpis ;
Liratzopoulos, Nikolaos ;
Efraimidou, Eleni ;
Panopoulou, Maria ;
Alepopoulou, Eleonora ;
Kartali-Ktenidou, Sofia ;
Manolas, Konstantinos .
INTENSIVE CARE MEDICINE, 2007, 33 (09) :1533-1540