title: Antibiotic de-escalation in the ICU: how is it best done?
abstract: OBJECTIVE
  An antimicrobial policy consisting of the initial use of wide-spectrum antimicrobials followed by a reassessment of treatment when culture results are available is termed de-escalation therapy. Our aim is to examine the safety and feasibility of antibiotic de-escalation in critically ill patients providing practical tips about how to accomplish this strategy in the critical care setting.
  
  
  RESULTS
  Numerous studies have assessed the rates of de-escalation therapy (range from 10 to 60%) in patients with severe sepsis or ventilator-associated pneumonia as well as the factors associated with de-escalation. De-escalation generally refers to a reduction in the spectrum of administered antibiotics through the discontinuation of antibiotics or switching to an agent with a narrower spectrum. Diverse studies have identified the adequacy of initial therapy as a factor independently associated with de-escalation. Negative impact on different outcome measures has not been reported in the observational studies. Two randomized clinical trials have evaluated this strategy in patients with ventilator-associated pneumonia or severe sepsis. These trials alert us about the possibility that this strategy may be linked to a higher rate of reinfections but without an impact on mortality.
  
  
  CONCLUSIONS
  Antibiotic de-escalation is a well tolerated management strategy in critically ill patients but unfortunately is not widely adopted.
authors.affiliation: aCritical Care and Emergency Department, Intensive Care Unit, Virgen del Rocío University Hospital bInstituto de Biomedicina de Sevilla (IBIS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla cSpanish Network for Research in Infectious Disease (REIPI), Virgen del Rocío University Hospital, Sevilla, Spain.
authors.forename: Jose
authors.initials: J
authors.lastname: Garnacho-Montero
authors.forename: Ana
authors.initials: A
authors.lastname: Escoresca-Ortega
authors.forename: Esperanza
authors.initials: E
authors.lastname: Fernández-Delgado
mesh_terms: D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D003422:Critical Care / Q000379:methods*; D016638:Critical Illness; D004358:Drug Therapy / Q000379:methods; D006801:Humans
chemical_list: D000900:Anti-Bacterial Agents