title: De-Escalation of Antibiotics Does Not Increase Mortality in Critically Ill Surgical Patients.
abstract: BACKGROUND
  Overuse of broad-spectrum antibiotics results in microbial resistance and financially is a healthcare burden. Antibiotic de-escalation refers to starting treatment of a presumed infection with broad-spectrum antibiotics and narrowing drug spectrum based on culture sensitivities. A study was designed to evaluate antibiotic de-escalation at a tertiary care center. We hypothesized that antibiotic de-escalation would not be associated with increased patient mortality rates or worsening of the primary infection.
  
  
  METHODS
  All infections treated in a single, tertiary care Surgical ICU between August 2009 and December 2011 were reviewed. Antibiotic treatment was classified by skilled reviewers as being either de-escalated or not. Outcomes were evaluated. Univariate statistics were performed (Fisher exact test, Chi-square for categorical data; student t-test for continuous variables). Multivariable logistic regression was completed.
  
  
  RESULTS
  A total of 2,658 infections were identified. De-escalation was identified for 995 infections and non-deescalation occurred in 1,663. Patients were similar in age (de-escalated 55 ± 16 y vs. 56 ± 16, p = 0.1) and gender (de-escalated 60% males vs. 58%, p = 0.4). There were substantially greater APACHE II scores in non-deescalated patients (15 ± 8 vs. 14 ± 8, p = 0.03). A greater mortality rate among patients with infections treated without de-escalation was observed compared with those treated with de-escalation (9% vs. 6%, p = 0.002). Total antibiotic duration was substantially longer in the de-escalated group (15 ± 13 d vs. 13 ± 13, p = 0.0001). Multivariable analysis found that de-escalation decreased mortality rates (OR = 0.69; 95%CI, 0.49-0.97; p = 0.04) and high APACHE II score independently increased mortality rates (OR = 1.2; 95%CI, 1.1-1.2; p = 0.0001). Other parameters included were age and infection site.
  
  
  CONCLUSIONS
  Antibiotic de-escalation was not associated with increased mortality rates, but the duration of antibiotic use was longer in this group. Greater mortality rates were observed in the non-deescalated group, but this likely owes at least in part to their relatively greater severity of disease classification (APACHE II). Further investigation will help evaluate whether antibiotic de-escalation will improve the quality of patient care.
authors.affiliation: Department of Surgery, Division of Acute Care Surgery, University of Virginia , Charlottesville, Virginia.
authors.forename: Kristin C
authors.initials: KC
authors.lastname: Turza
authors.affiliation: Department of Surgery, Division of Acute Care Surgery, University of Virginia , Charlottesville, Virginia.
authors.forename: Amani D
authors.initials: AD
authors.lastname: Politano
authors.affiliation: Department of Surgery, Division of Acute Care Surgery, University of Virginia , Charlottesville, Virginia.
authors.forename: Laura H
authors.initials: LH
authors.lastname: Rosenberger
authors.affiliation: Department of Surgery, Division of Acute Care Surgery, University of Virginia , Charlottesville, Virginia.
authors.forename: Lin M
authors.initials: LM
authors.lastname: Riccio
authors.affiliation: Department of Surgery, Division of Acute Care Surgery, University of Virginia , Charlottesville, Virginia.
authors.forename: Matthew
authors.initials: M
authors.lastname: McLeod
authors.affiliation: Department of Surgery, Division of Acute Care Surgery, University of Virginia , Charlottesville, Virginia.
authors.forename: Robert G
authors.initials: RG
authors.lastname: Sawyer
mesh_terms: D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D001424:Bacterial Infections / Q000188:drug therapy* / Q000401:mortality*; D016638:Critical Illness; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D016019:Survival Analysis; D062606:Tertiary Care Centers
chemical_list: D000900:Anti-Bacterial Agents