title: De-escalation of antimicrobials in the treatment of bacteraemia due to antibiotic-sensitive pathogens in immunocompetent patients.
abstract: BACKGROUND
  The aim of this study was to examine the safety and efficacy of de-escalating antimicrobial therapy in immunocompetent patients presenting with bacteraemia due to antibiotic-sensitive pathogens.
  
  
  METHODS
  We screened 1,350 positive blood cultures identified in a single, 1,065-bed university hospital over 5 years, and retained 310 cases of bacteraemia due to antibiotic-sensitive pathogens, including (1) methicillin-sensitive staphylococci, (2) penicillin-sensitive streptococci, (3) β-lactam-sensitive (a) Escherichia coli, and (b) Klebsiella species. The efficacy of appropriate initial empirical antimicrobial therapy, the performance of de-escalated pathogen-directed therapy, and the safety and efficacy of de-escalated therapy were evaluated.
  
  
  RESULTS
  Among 270 appropriately treated patients, 16 (6%) died, versus 6 (15%) among 40 who were inappropriately treated (p = 0.04). While 201 of 270 patients (74%) who received appropriate initial empirical therapy were candidates for de-escalation, the treatment was de-escalated in only 79 (39%). De-escalation was associated with (1) a trend toward a lower (a) death rate (1 vs. 5%) and (b) treatment failure (4 vs. 10%), and (2) (a) a 4-day longer median duration and (b) a $50 higher median cost of antimicrobial therapy (p < 0.001).
  
  
  CONCLUSIONS
  When the pathogen was sensitive to antimicrobial therapy and the initial empirical treatment was effective, de-escalation of antimicrobial therapy in immunocompetent patients with bacteraemia was safe and associated with acceptable outcomes. The rate of de-escalation of antimicrobial therapy was low.
authors.affiliation: Department of Anaesthesiology and Intensive Care, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto 602-8566, Japan. shime@koto.kpu-m.ac.jp
authors.forename: N
authors.initials: N
authors.lastname: Shime
authors.forename: S
authors.initials: S
authors.lastname: Satake
authors.forename: N
authors.initials: N
authors.lastname: Fujita
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D016470:Bacteremia / Q000188:drug therapy* / Q000276:immunology* / Q000401:mortality; D003422:Critical Care / Q000379:methods*; D003663:Decision Trees; D004755:Enterobacteriaceae / Q000187:drug effects; D004756:Enterobacteriaceae Infections / Q000188:drug therapy / Q000382:microbiology / Q000401:mortality; D005260:Female; D006094:Gram-Positive Bacteria / Q000187:drug effects; D016908:Gram-Positive Bacterial Infections / Q000188:drug therapy* / Q000276:immunology* / Q000401:mortality; D006801:Humans; D016867:Immunocompromised Host; D007564:Japan; D008297:Male; D008875:Middle Aged; D010406:Penicillins / Q000627:therapeutic use; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome; D047090:beta-Lactams / Q000627:therapeutic use
chemical_list: D000900:Anti-Bacterial Agents; D010406:Penicillins; D047090:beta-Lactams