Impact of de-escalation of beta-lactam antibiotics on the emergence of antibiotic resistance in ICU patients: a retrospective observational study

被引:59
作者
De Bus, Liesbet [1 ]
Denys, Wouter [1 ]
Catteeuw, Julie [1 ]
Gadeyne, Bram [1 ]
Vermeulen, Karel [2 ]
Boelens, Jerina [3 ]
Claeys, Geert [3 ]
De Waele, Jan J. [1 ]
Decruyenaere, Johan [1 ]
Depuydt, Pieter O. [1 ,4 ]
机构
[1] Ghent Univ Hosp, Dept Crit Care Med, De Pintelaan 185, B-9000 Ghent, Belgium
[2] Univ Ghent, Dept Math Modelling Stat & Bioinformat, B-9000 Ghent, Belgium
[3] Ghent Univ Hosp, Dept Lab Med, De Pintelaan 185, B-9000 Ghent, Belgium
[4] Univ Ghent, Heymans Inst Pharmacol, B-9000 Ghent, Belgium
关键词
Beta-lactam antibiotics; Antibiotic stewardship; Multi-drug resistance; De-escalation; Information technology system; INTENSIVE-CARE-UNIT; SEVERE SEPSIS; COMPETING RISKS; ANTIMICROBIAL TREATMENT; INFECTION SURVEILLANCE; THERAPY; GUIDELINES; MANAGEMENT; PNEUMONIA; STRATEGY;
D O I
10.1007/s00134-016-4301-z
中图分类号
R4 [临床医学];
学科分类号
1002 ; 100602 ;
摘要
Purpose: Antibiotic de-escalation is promoted to limit prolonged exposure to broad-spectrum antibiotics, but proof that it prevents the emergence of resistance is lacking. We evaluated determinants of antibiotic de-escalation in an attempt to assess whether the latter is associated with a lower emergence of antimicrobial resistance. Methods: Antibiotic treatments, starting with empirical beta-lactam prescriptions, were prospectively documented during 2013 and 2014 in a tertiary intensive care unit (ICU) and categorized as continuation, de-escalation or escalation of the empirical antimicrobial treatment. Determinants of the de-escalation or escalation treatments were identified by multivariate logistic regression; the continuation category was used as the reference group. Using systematically collected diagnostic and surveillance cultures, we estimated the cumulative incidence of antimicrobial resistance following de-escalation or continuation of therapy, with adjustment for ICU discharge and death as competing risks. Results: Of 478 anti-pseudomonal antibiotic prescriptions, 42 (9 %) were classified as escalation of the antimicrobial treatment and 121 (25 %) were classified as de-escalation, mainly through replacement of the originally prescribed antibiotics with those having a narrower spectrum. In multivariate analysis, de-escalation was associated with the identification of etiologic pathogens (p < 0.001). The duration of the antibiotic course in the ICU in de-escalated versus continued prescriptions was 8 (range 6-10) versus 5 (range 4-7) days, respectively (p < 0.001). Mortality did not differ between patients in the de-escalation and continuation categories. The cumulative incidence estimates of the emergence of resistance to the initial beta-lactam antibiotic on day 14 were 30.6 and 23.5 % for de-escalation and continuation, respectively (p = 0.22). For the selection of multi-drug resistant pathogens, these values were 23.5 (de-escalation) and 18.6 % (continuation) respectively (p = 0.35). Conclusion: The emergence of antibiotic-resistant bacteria after exposure to anti-pseudomonal beta-lactam antibiotics was not lower following de-escalation.
引用
收藏
页码:1029 / 1039
页数:11
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