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J. Garnacho-Montero, A. Gutiérrez-
Pizarraya, A. Escoresca-Ortega,
Y. Corcia-Palomo, Esperanza
Fernández-Delgado, I. Herrera-Melero,
et al.
Intensive Care Medicine
ISSN 0342-4642
1 23
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Author's personal copy
Intensive Care Med
DOI 10.1007/s00134-013-3077-7 ORIGINAL ARTICLE
J. Garnacho-Montero
A. Gutiérrez-Pizarraya
De-escalation of empirical therapy is
A. Escoresca-Ortega associated with lower mortality in patients
Y. Corcia-Palomo
Esperanza Fernández-Delgado with severe sepsis and septic shock
I. Herrera-Melero
C. Ortiz-Leyba
J. A. Márquez-Vácaro
accordance with current medical standards. Antibiotic analysis was performed using SPSS for Windows 15.0.0
strategies once culture results were available were clas- (SPSS, Chicago, IL, USA).
sified as: ‘‘no change’’ (empirical therapy was maintained
without modification), ‘‘escalation of therapy’’ (the switch
to or addition of an antibiotic with a broader spectrum),
and ‘‘de-escalation’’ (switch to or interruption of a drug Results
class resulting in a less broad spectrum of coverage). If
antimicrobial change consisted of escalation and de- During the study period, 712 patients were admitted to the
escalation (i.e. switch to or addition of an antibiotic with a ICU with the diagnosis of severe sepsis (n = 278) or
broader spectrum but also withdrawal of another antibi- septic shock (n = 434). Mean delay to microbiological
otic), the patient was assigned to ‘‘escalation group’’ for results was 72 h (48–96). Eighty-four patients died before
statistical analysis. culture results were available for the clinician in charge of
We grouped de-escalation in the following categories: the patient and were excluded from this analysis.
withdrawal of one antimicrobial (group I); withdrawal of
two of the antimicrobials empirically prescribed (group
II); switch to a new antimicrobial with narrower spectrum Entire cohort
(group III); and withdrawal of at least one antimicrobial
plus change of another drug to a new one with narrower In these 628 patients in whom evaluation of the empirical
spectrum (group IV). therapy could be accomplished, microbiological docu-
Development of nosocomial infections in the ICU was mentation was obtained in 481 of the episodes (76.7 %).
also noted following previously published definitions Bacteremia was detected in 241 patients (38.4 %), and
[15]. All patients were followed up until death or hospital 403 patients (87.6 %) received adequate empirical ther-
discharge. Vital status of patients discharged from the apy. Pathogens isolated in blood cultures and at the site of
hospital before 90 days of admission was ascertained infections are depicted in Table 1 of the Electronic Sup-
consulting the hospital database or by telephone contact. plementary Material (ESM). In 131 episodes, an organism
included in the ESKAPE group was isolated either in
blood or in the infectious focus. ICU mortality was
Statistical analysis 29.5 % (185 patients), in-hospital mortality 33.4 % (210
patients), and 90-day mortality rose up to 35.2 % (221
Discrete variables were expressed as counts (percentage) patients).
and continuous variables as medians and interquartile Of these 628 patients, 296 (47.1 %) patients received
ranges (IQRs). Differences in categorical variables were monotherapy in the empirical therapy, 249 (39.7 %)
calculated using a two-sided likelihood ratio Chi square received two antimicrobials, and three or more antimi-
test or Fisher exact test, and the Mann–Whitney U test or crobials were used in 83 patients (13.2 %). In patients
Kruskal–Wallis test were used for continuous variables, with monotherapy, the prescribed antibiotics were:
when appropriate. piperacillin-tazobactam (72.3 %), followed by a carba-
A logistic regression model was carried out to assess penem (22.2 %), third-generation cephalosporins or
the impact of independent variables on in-hospital mor- cefepime (2.4 %), fluoroquinolones (1.7 %), and others
tality (primary goal) and 90-day mortality (secondary (1.4 %). The most frequently prescribed combinations of
goal). We considered the ‘‘no change’’ category as the antimicrobials were a third-generation cephalosporin or
reference and it was compared with the two others. cefepime plus a fluoroquinolone or a glycopeptide fol-
Variables significantly associated with mortality in the lowed by a carbapenem plus a glycopeptide. De-
univariate analysis or if they were considered clinically escalation therapy was performed in 219 patients
significant were entered into the model (statistical ana- (34.9 %) and consisted of: 88 strategy I, 20 strategy II, 80
lysis in the ESM). strategy III, and 31 strategy IV.
Furthermore, to assess the impact of treatment (de- Regarding the characteristics of patients according to
escalation use; non de-escalation use) on mortality and to antibiotic strategy, de-escalation therapy was more com-
control for confounders, a propensity score adjusted- monly performed in medical than in surgical patients
multivariable analysis was also performed. All informa- (Table 2 of the ESM). Severity of illness in the first 24 h
tion about how the propensity score was constituted and of ICU admission did not influence antimicrobial therapy
the multivariable model adjusted by the propensity score modification. In contrast, the SOFA score on the day of
is described in the statistical analysis section in the ESM culture results was higher in those patients in whom
[16]. Adjusted OR are presented with corresponding 95 % therapy was escalated compared with the other two
CI. All reported p values were two-tailed. The threshold groups. The rate of adequate antimicrobial therapy was
for statistical significance was defined as p \ 0.05. Data lower in those patients for whom the physician in charge
Author's personal copy
of the patient decided on escalatation. According to pat- Regarding mortality at 90 days, factors associated
terns of antibiotic strategy (Fig. 1), the hospital mortality with fatality by multivariate analysis were: septic shock
rate was 27.4 % in patients in whom therapy was de- (OR 1.81; 95 % CI 1.10–2.98; p = 0.019), inadequate
escalated, 32.6 % in the category of ‘‘no change’’, and empirical antimicrobial therapy (OR 1.92; 95 % CI
42.9 % in the escalation group (p = 0.006). ICU and 1.02–3.62; p = 0.043) and SOFA score on the day of
90-day mortalities were also lower in the de-escalation culture results (OR 1.11; 95 % CI 1.06–1.17; p \ 0.001)
group, intermediate in the group of ‘‘no change’’, and whereas de-escalation therapy was a protective factor (OR
greater in the escalation group. 0.55; 95 % CI 0.34–0.87; p = 0.011). In the propensity
Bivariate analysis of risk factors associated with mor- score adjusted model, de-escalation therapy was associ-
tality is depicted in Table 1. Patients who died in the hospital ated with reduced 90-day mortality.
were significantly older and with a more severe disease at
admission assessed by APACHE II and SOFA scores.
Similarly, the SOFA score on the day of culture results were Patients with adequate empirical antimicrobial therapy
significantly greater in patients who died during hospital-
ization. Rate of de-escalation therapy was significantly We also analyzed the 438 patients with adequate empir-
higher in patients who survived (38 vs. 28.6 %; p = 0.019). ical therapy but excluding 35 patients who died before
APACHE II score at admission to the ICU was divided into microbiological results were available (Table 3). In the
four quartiles. The rate of de-escalation was not statistically empirical therapy, 184 patients received monotherapy,
different among these four quartiles (Fig. 1 of the ESM). By 161 received combination therapy with two antimicrobi-
multivariate logistic regression analysis, factors indepen- als and the initial therapy included three or more
dently associated with mortality were septic shock, SOFA antimicrobials in 58 patients. Rate of nosocomial infec-
score on the day of culture results, and inadequate empirical tion in patients with ICU length of stay greater than
antimicrobial therapy, whereas de-escalation therapy was a 5 days was higher in patients in whom antimicrobial
protective factor (Table 1). therapy was de-escalated compared to the ‘‘no change’’
Because of the noted imbalances in baseline charac- group although this difference was not statistically sig-
teristics and clinical situation on the day of culture results nificant: 25/148 (16.9 %) vs. 29/116 (25 %); p = 0.1. De-
among patients according to antibiotic strategy, a logistic escalation therapy was accomplished in 179 patients
regression model was developed introducing the proba- (44.4 %), in 147 patients (36.5 %) the empirical therapy
bility calculated by the propensity score in an attempt to was maintained and in 77 cases (19.1 %) therapy was
ameliorate the impact of observed differences. This ana- escalated although the empirical therapy was adequate.
lysis also identified de-escalation therapy as a protective De-escalation consisted in: 68 strategy I, 15 strategy II, 67
factor for in-hospital mortality (Table 2). strategy III and 29 strategy IV. Figure 1 depicts that the
Table 1 Bivariate and multivariate analysis of risk factors associated with hospital mortality in the total cohort
SOFA day of culture results 1.11 (1.04–1.23) \0.001 1.18 (1.16–1.29) \0.001
Septic shock 1.70 (1.03–2.84) 0.043
Inadequate empirical treatment 2.03 (1.06–3.84) 0.030
De-escalation 0.55 (0.32–0.98) 0.022 0.57 (0.38–0.94) 0.019
hospital mortality rate was 24.6 % in de-escalation ther- in these two groups. In-hospital and 90-day mortalities
apy group, 32 % in patients who were kept on broad- were higher in patients in whom antimicrobial therapy
spectrum empirical therapy and 44.2 % in the escalation was de-escalated compared to the ‘‘no change’’ group
group (p = 0.008). We also compared these 179 patients although only the latter archived statistical significance
in whom de-escalation was performed with 180 patients (24.5 vs. 32.8 %; p = 0.08 and 25.1 vs. 36.1 %;
without de-escalation despite that the microbiology p = 0.024, respectively).
results allowed simplification of the antimicrobial regi- As shown in Table 3, APACHE II score in the first
men. APACHE II score and SOFA at admission as well as 24 h and SOFA scores at admission and on the day of
the SOFA score on the day of culture results were similar culture results were significantly higher in those patients
Author's personal copy
Table 3 Bivariate and multivariate analysis of risk factors associated with mortality in patients with adequate empirical antimicrobial
therapy
to recommend for or against antimicrobial de-escalation groups of patients. In our series, de-escalation was
in adults with a diagnosis of sepsis, requiring further achieved with the same frequency by reducing the number
research via randomized controlled trials or large cohort of drugs and by narrowing the spectrum of antibiotic
studies [9]. therapy. Conversely, others have found that de-escalation
De-escalation therapy has been predominantly evalu- is achieved more often by reducing the number of drugs
ated in patients with hospital-acquired pneumonia. Kollef [21, 22]. We also found that de-escalation therapy is less
et al. [6] reported in 398 patients with severe sepsis or frequently accomplished in surgical patients than in
septic shock and the ICU mortality rate was significantly medical admissions. Surgical infections (i.e. peritonitis or
lower among patients in whom therapy was de-escalated soft tissue infections) are frequently polymicrobial, which
compared with those experiencing therapy escalation or may explain the difficulties in reducing or narrowing the
those in whom therapy remained unchanged. Similarly, antimicrobial spectrum.
Rello et al. [5] observed that the ICU mortality rate of As previously reported [1–4], inadequate empiric
patients with de-escalation therapy was significantly antibiotic therapy is also an independent predictor of
lower than in patients in whom the empirical therapy was mortality in critically ill septic patients. More impor-
maintained. In 137 patients diagnosed with ICU-acquired tantly, we have demonstrated that, after controlling for
pneumonia, the de-escalation group showed significantly potential confounders including severity of illness on the
lower crude and pneumonia-related mortality rates by day day of culture results, de-escalation therapy is associated
30 after pneumonia diagnosis [17]. Nevertheless, this with a lower mortality rate. Interestingly, this survival
strategy was not identified as a protective factor by the benefit is also manifest in patients who had received
multivariate analysis. In another study that included adequate empirical therapy.
microbiologically confirmed episodes of VAP, patients in Moreover, censoring the mortality data at ICU or
whom treatment was de-escalated had significantly hospital discharge may significantly underestimate the
reduced 15-day and 28-day mortality, compared to medium- and long-term effects of sepsis. In fact, a not
patients who were kept on broad-spectrum empirical insignificant number of septic patients discharged alive
therapy [18]. from an ICU die in the subsequent months [25]. It is
De-escalation therapy has also been assessed in other noteworthy that, in our study, the favorable effect in terms
populations. Thus, in non-immunosuppressed patients of survival of de-escalation therapy persists in the
with bacteremia treated adequately in the initial regimen, 3-month follow-up.
de-escalation was safe and associated with a trend Several plausible reasons may explain the benefits in
towards lower mortality and treatment failure rates, terms of survival of de-escalation therapy, especially in
although mortality was very low (3.5 %) [19]. The same comparison with those patients in whom empirical ther-
group has recently reported that de-escalation therapy is apy was maintained unaltered. In certain situations, this
feasible and safe in bacteremia caused by difficult-to-treat favorable effect might be produced for the use of less
Gram-negative bacilli in patients who had received ade- toxic antibiotics (i.e. withdrawal of nephrotoxic agents),
quate empirical therapy [20]. by the administration of antibiotics that achieve higher
Data on patients with severe sepsis and septic shock concentrations at the infection focus (i.e. in case of
are lacking. In one prospective study that enrolled patients meningitis), or by the election of more active agents. For
with septic shock, de-escalation therapy was performed in instance, it is known that beta-lactams are more active
64 % of cases [21]. Three recent retrospective studies than glycopeptides against susceptible Gram-positive
have documented that de-escalation of empirical therapy cocci. In fact, prognosis of meticillin susceptible S. aur-
is accomplished in roughly 50 % of critically ill patients eus bacteremia is worse in patients treated with
with sepsis [8, 22]. In patients with severe nosocomial vancomycin than in those who received a beta-lactam
infections, escalation was performed more frequently that [26]. Moreover, the risk of nosocomial infection caused
true de-escalation therapy, reflecting the high rate of by multi-drug resistant pathogen is lower if the spectrum
multidrug-resistant Gram-negative pathogens found in of antimicrobial therapy is narrowed. In our series, the
this multicenter study [23]. However, these studies did not rate of nosocomial infection was similar between these
specifically analyze the impact on clinical outcomes, groups although a non-significant trend towards a higher
although no excess of mortality was observed even in rate of infection acquired in the ICU was documented in
patients with septic shock [22, 24]. patients with adequate therapy and a length of ICU stay
Our rate of de-escalation of the antimicrobial therapy longer than 5 days. The highest rate of ICU-acquired
was approximately one-third in the entire cohort and rose infection was observed in the escalation group (53 % of
to 44.4 % in patients with adequate empirical therapy. them had received inadequate empirical therapy).
Severity of the illness at ICU admission did not influence Development of nosocomial infection is significantly
our decision to de-escalate. As expected, patients in more frequent in patients with inadequate empirical
whom the spectrum of antimicrobial therapy was broad- therapy than in those treated empirically with adequate
ened were in a more critical condition than the other two antibiotics [27].
Author's personal copy
The deleterious effects of the administration of broad- share similar characteristics. Fourth, we have not evalu-
spectrum antibiotics are well documented [28]. Hence, for ated the applicability of de-escalation therapy in
critically ill patients without confirmed nosocomial infections caused by multidrug-resistant pathogens in
infection, maintenance of the empirical antimicrobial which the use of combination therapy is recommended by
therapy was associated with a higher 28-day mortality rate most of the experts which makes it generally impossible
than for those in whom antibiotics were stopped. When to stop one antimicrobial [7, 31]. In our study, which
potential confounding variables were controlled for in a included patients at ICU admission, a relatively low
multivariable model, the association between continua- prevalence of ESKAPE organisms was observed.
tion of therapy and mortality showed a strong trend In conclusion, an early and adequate antimicrobial
towards statistical significance (OR = 3.75, 0.91–15.49, treatment is undoubtedly a major prognostic factor in
p = 0.07) [29]. critically ill septic patients. Moreover, our findings clearly
We admit several limitations of our study. First, the support that the empiric coverage should be refined once
gold standard for demonstrating that a therapeutic inter- culture results are available. Therefore, in patients with
vention impacts on the outcome is a randomized, severe sepsis and septic shock at admission to the ICU,
controlled, blinded trial. When these kinds of trials are the optimal management includes the administration of
lacking, observational studies can provide valuable broad-spectrum antibiotics together with reassessment
information about treatment effectiveness. Statistical and subsequent narrowing or discontinuation of therapy
adjustments using the estimated propensity score have the based on the results of cultures and antibacterial suscep-
advantage of balancing recorded covariates, thus pro- tibility tests. All initiatives to improve antibiotic
ducing a situation closer to randomization. However, in prescriptions in critically ill septic patients are completely
our study, we report the conventional regression analysis warranted and should include the streamlining of empir-
and the propensity score-adjusted analysis because ical antibiotics.
sometimes the latter may be superior to propensity score
methods regarding to precision and bias control [16]. Acknowledgments Supported by Ministerio de Economı́a y
Importantly, both approaches coincide that de-escalation Competitividad, Instituto de Salud Carlos III - co-financed by
European Development Regional Fund ‘‘A way to achieve Europe’’
therapy is associated with a lower mortality. Second, a ERDF, Spanish Network for the Research in Infectious Diseases
delay of 24 h in starting adequate treatment is not (REIPI RD12/0015).
acceptable in case of septic shock because the prognosis
of these patients is clearly influenced by the timing of Conflicts of interest The authors declare that they have no con-
antimicrobial therapy [30]. Third, this is a single-center flict of interest.
study carried out in a large academic hospital and our
results might not be generalizable to centers that do not
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