Antibiotic de–escalation as an antimicrobial stewardship measure in emergency and critical care

Abstract

To save severely septic patients and simultaneously prevent the emergence of resistant bacteria, antibiotics should be administered empirically and then de–escalated promptly, after bacterial susceptibility is confirmed. De–escalation therapy for septic shock is a safe strategy associated with lower mortality; however, its incidence is not high in Intensive Care Units (ICU). From 76 patients admitted to our ICU with a diagnosis of sepsis, most of surgical patients were infected with community–acquired agents including digestive infections. Broad–spectrum antibiotics were used empirically in ＞90％ patients; approximately 20％ surgical patients received more than one drug. The adequate rate of empirical therapy was about 95％. Antibiotic de–escalation therapy was performed in 50％ of cases receiving broad–spectrum antibiotics. There were various reasons behind the hesitancy to apply de–escalation therapy to severely ill patients: unknown causative agent, no visible improvement of pathological conditions, presence of multiple infection foci, and immunosuppression. In order to promote the proper use of antibiotics in ICU, in addition to a strong cooperation between clinicians, antimicrobial stewardship team, and ICU–dedicated pharmacists, critically ill patients’ treatment should be carried out rationally in accordance with the basic treatment logic for infectious diseases, and in parallel a rapid bacteria diagnostic method should be applied.