title: Frequency of empiric antibiotic de-escalation in an acute care hospital with an established Antimicrobial Stewardship Program.
abstract: BACKGROUND
  Expanding antimicrobial resistance patterns in the face of stagnant growth in novel antibiotic production underscores the importance of antibiotic stewardship in which de-escalation remains an integral component. We measured the frequency of antibiotic de-escalation in a tertiary care medical center with an established antimicrobial stewardship program to provide a plausible benchmark for de-escalation.
  
  
  METHODS
  A retrospective, observational study was performed by review of randomly selected electronic medical records of 240 patients who received simultaneous piperacillin/tazobactam and vancomycin from January to December 2011 at an 885-bed tertiary care medical center. Patient characteristics including antibiotic regimen, duration and indication, culture results, length of stay, and hospital mortality were evaluated. Antibiotic de-escalation was defined as the use of narrower spectrum antibiotics or the discontinuation of antibiotics after initiation of piperacillin/tazobactam and vancomycin therapy. Subjects dying within 72 h of antibiotic initiation were considered not de-escalated for subsequent analysis and were subtracted from the study population in determining a modified mortality rate.
  
  
  RESULTS
  The most commonly documented indications for piperacillin/tazobactam and vancomycin therapy were pneumonia and sepsis. Of the 240 patients studied, 151 (63%) had their antibiotic regimens de-escalated by 72 h. The proportion of patients de-escalated by 96 h with positive vs. negative cultures was similar, 71 and 72%, respectively. Median length of stay was 4 days shorter in de-escalated patients, and the difference in adjusted mortality was not significant (p = 0.82).
  
  
  CONCLUSIONS
  The empiric antibiotic regimens of approximately two-thirds of patients were de-escalated by 72 h in an institution with a well-established antimicrobial stewardship program. While this study provides one plausible benchmark for antibiotic de-escalation, further studies, including evaluations of antibiotic appropriateness and patient outcomes, are needed to inform decisions on potential benchmarks for antibiotic de-escalation.
authors.affiliation: Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157, USA. PWL6M@hscmail.mcc.virginia.edu.
authors.forename: Peter
authors.initials: P
authors.lastname: Liu
authors.affiliation: Wake Forest School of Medicine, Section on Infectious Diseases, Medical Center Boulevard, Winston-Salem, NC, 27157, USA.
authors.forename: Christopher
authors.initials: C
authors.lastname: Ohl
authors.affiliation: Wake Forest Baptist Health, Medical Center Boulevard, Winston-Salem, NC, 27157, USA.
authors.forename: James
authors.initials: J
authors.lastname: Johnson
authors.affiliation: Wake Forest Baptist Health, Medical Center Boulevard, Winston-Salem, NC, 27157, USA.
authors.forename: John
authors.initials: J
authors.lastname: Williamson
authors.affiliation: Wake Forest Baptist Health, Medical Center Boulevard, Winston-Salem, NC, 27157, USA.
authors.forename: James
authors.initials: J
authors.lastname: Beardsley
authors.affiliation: Wake Forest School of Medicine, Section on Infectious Diseases, Medical Center Boulevard, Winston-Salem, NC, 27157, USA.
authors.forename: Vera
authors.initials: V
authors.lastname: Luther
mesh_terms: D000208:Acute Disease; D000368:Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D024881:Drug Resistance, Bacterial; D004359:Drug Therapy, Combination; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010397:Penicillanic Acid / Q000031:analogs & derivatives* / Q000627:therapeutic use; D010878:Piperacillin / Q000627:therapeutic use; D000077725:Piperacillin, Tazobactam Drug Combination; D011014:Pneumonia / Q000188:drug therapy*; D012189:Retrospective Studies; D018805:Sepsis / Q000188:drug therapy*; D014640:Vancomycin / Q000627:therapeutic use*
chemical_list: D000900:Anti-Bacterial Agents; D000077725:Piperacillin, Tazobactam Drug Combination; D014640:Vancomycin; D010397:Penicillanic Acid; D010878:Piperacillin
keywords: Antibiotic de-escalation; Antibiotic stewardship; Antimicrobial stewardship program; Benchmark; Prospective audit and feedback