title: Characteristics and outcomes of anti-infective de-escalation during health care-associated intra-abdominal infections.
abstract: BACKGROUND
  De-escalation is strongly recommended for antibiotic stewardship. No studies have addressed this issue in the context of health care-associated intra-abdominal infections (HCIAI). We analyzed the factors that could interfere with this process and their clinical consequences in intensive care unit (ICU) patients with HCIAI.
  
  
  METHODS
  All consecutive patients admitted for the management of HCIAI who survived more than 3 days following their diagnosis, who remained in the ICU for more than 3 days, and who did not undergo early reoperation during the first 3 days were analyzed prospectively in an observational, single-center study in a tertiary care university hospital.
  
  
  RESULTS
  Overall, 311 patients with HCIAI were admitted to the ICU. De-escalation was applied in 110 patients (53%), and no de-escalation was reported in 96 patients (47%) (escalation in 65 [32%] and unchanged regimen in 31 [15%]). Lower proportions of Enterococcus faecium, nonfermenting Gram-negative bacilli (NFGNB), and multidrug-resistant (MDR) strains were cultured in the de-escalation group. No clinical difference was observed at day 7 between patients who were de-escalated and those who were not. Determinants of de-escalation in multivariate analysis were adequate empiric therapy (OR 9.60, 95% CI 4.02-22.97) and empiric use of vancomycin (OR 3.39, 95% CI 1.46-7.87), carbapenems (OR 2.64, 95% CI 1.01-6.91), and aminoglycosides (OR 2.31 95% CI 1.08-4.94). The presence of NFGNB (OR 0.28, 95% CI 0.09-0.89) and the presence of MDR bacteria (OR 0.21, 95% CI 0.09-0.52) were risk factors for non-de-escalation. De-escalation did not change the overall duration of therapy. The risk factors for death at day 28 were presence of fungi (HR 2.64, 95% CI 1.34-5.17), Sequential Organ Failure Assessment score on admission (HR 1.29, 95% CI 1.16-1.42), and age (HR 1.03, 95% CI 1.01-1.05). The survival rate expressed by a Kaplan-Meier curve was similar between groups (log-rank test p value 0.176).
  
  
  CONCLUSIONS
  De-escalation is a feasible option in patients with polymicrobial infections such as HCIAI, but MDR organisms and NFGNB limit its implementation.
authors.affiliation: Département d'Anesthésie Réanimation, APHP, CHU Bichat-Claude Bernard, Paris, France. philippe.montravers@aphp.fr.|Université Denis Diderot, PRESS Sorbonne Cité, Paris, France. philippe.montravers@aphp.fr.
authors.forename: Philippe
authors.initials: P
authors.lastname: Montravers
authors.affiliation: Département d'Anesthésie Réanimation, APHP, CHU Bichat-Claude Bernard, Paris, France.
authors.forename: Pascal
authors.initials: P
authors.lastname: Augustin
authors.affiliation: Université Denis Diderot, PRESS Sorbonne Cité, Paris, France.|INSERM, UMR 1137, Infection, Antimicrobiens, Modélisation, Evolution, Paris, France.|Laboratoire de Microbiologie, AP-HP, CHU Bichat-Claude Bernard, Paris, France.
authors.forename: Nathalie
authors.initials: N
authors.lastname: Grall
authors.affiliation: Département d'Anesthésie Réanimation, APHP, CHU Bichat-Claude Bernard, Paris, France.|Service de Réanimation, Centre Hospitalier Sud Francilien, Corbeil-Essonnes, France.
authors.forename: Mathieu
authors.initials: M
authors.lastname: Desmard
authors.affiliation: Département d'Anesthésie Réanimation, APHP, CHU Bichat-Claude Bernard, Paris, France.
authors.forename: Nicolas
authors.initials: N
authors.lastname: Allou
authors.affiliation: Université Denis Diderot, PRESS Sorbonne Cité, Paris, France.|Service de Chirurgie Générale, APHP, CHU Bichat-Claude Bernard, Paris, France.
authors.forename: Jean-Pierre
authors.initials: JP
authors.lastname: Marmuse
authors.affiliation: Département d'Anesthésie Réanimation, APHP, CHU Bichat-Claude Bernard, Paris, France.|Université Denis Diderot, PRESS Sorbonne Cité, Paris, France.|INSERM, UMR 1137, Infection, Antimicrobiens, Modélisation, Evolution, Paris, France.
authors.forename: Jean
authors.initials: J
authors.lastname: Guglielminotti
mesh_terms: D000368:Aged; D000900:Anti-Bacterial Agents / Q000008:administration & dosage* / Q000627:therapeutic use*; D003422:Critical Care / Q000379:methods*; D003428:Cross Infection / Q000401:mortality; D004352:Drug Resistance, Microbial / Q000276:immunology; D005260:Female; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data; D059413:Intraabdominal Infections / Q000188:drug therapy* / Q000401:mortality; D008297:Male; D008875:Middle Aged; D013997:Time Factors; D016896:Treatment Outcome; D014640:Vancomycin / Q000008:administration & dosage / Q000627:therapeutic use
chemical_list: D000900:Anti-Bacterial Agents; D014640:Vancomycin
keywords: Antibiotic therapy; De-escalation; Health care-associated intra-abdominal infections; Multidrug-resistant bacteria; Peritonitis