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Descalonamiento en Sepsis
Descalonamiento en Sepsis
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
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
who died than in patients that were discharged alive Discussion
from the hospital. As in the entire cohort, the rate of
de-escalation was not statistically different among the In this prospective, observational study, rates of de-
four APACHE II quartiles (Figure 1 of the ESM). escalation therapy in patients admitted to the ICU with
However, SOFA score on the day of culture results was severe sepsis or septic shock were about 35 %. We cor-
identified as a variable independently associated with roborate the safety of this antibiotic therapy and, more
in-hospital mortality by multivariate analysis whereas importantly, that after a strict adjustment for confounding
de-escalation therapy was a protective factor. Table 2 variables including baseline characteristics and severity of
shows that the propensity score-adjusted regression illness on the day of culture results, this antibiotic strategy
model also identified de-escalation therapy as a pro- is associated with a lower mortality.
tective factor for in-hospital mortality. Moreover, in The theory of streamlining antibiotics has been rec-
these 403 patients, both regression analyses coincided ommended for years, but there are not compelling data to
that de-escalation therapy was associated with lower support it in patients with severe sepsis or septic shock. In
mortality at 90 days. fact, a recent Cochrane review found insufficient evidence
Table 3 Bivariate and multivariate analysis of risk factors associated with mortality in patients with adequate empirical antimicrobial
therapy
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