title: Collaborative approach of individual participant data of prospective studies of de-escalation in non-immunosuppressed critically ill patients with sepsis.
abstract: BACKGROUND
  There is a concern to conduct de-escalation in very sick patients.
  
  
  OBJECTIVE
  To determine if de-escalation is feasible in ICU settings.
  
  
  METHODS
  We performed a metaanalysis of published studies conducted comparing de-escalation (defined by withdrawal of at least one antimicrobial empirically prescribed, switch to a new antimicrobial with narrower spectrum and withdrawal of at least one antimicrobial plus change of another drug to a new one with narrower spectrum) in non-immunocompromised patients with sepsis admitted to ICU.
  
  
  RESULTS
  Eight hundred and seventeen patients with severe sepsis or septic shock were evaluated. De-escalation was applied in 274 patients (33.5%). We found no differences in hospital long of stay between de-escalation group compared to those who did not receive it. We also found significant lower hospital mortality in de-escalation group as compared with no modification group in front of the others (25.9 vs. 43.1%; p < 0.001). Taking into account the etiology of infection, in both gram negative and gram positives microorganisms, de-escalation strategy was assessed as a good prognosis factor for mortality in the adjusted multivariate analysis (OR 0.41; 95% CI 0.22-0.74 and OR 0.33; 95% CI 0.15-0.70 respectively) whereas SOFA score along with age were found as a factors independently associated with a worse clinical outcome (OR 1.23; 95% CI 1.12-1.35 and OR 1.02; 95% CI 1.01-1.04 respectively).
  
  
  CONCLUSIONS
  In our study there was an independent association of de-escalation and decrease mortality rate.
authors.affiliation: a Department of Intensive Care Medicine , Instituto de Biomedicina de Sevilla, IBIS/Hospitales Universitarios Virgen Macarena -Virgen del Rocío /CSIC/Universidad de Sevilla , Sevilla , Spain.
authors.forename: Antonio
authors.initials: A
authors.lastname: Gutiérrez-Pizarraya
authors.affiliation: b Service d'anesthésie et de réanimation, Hôpital Nord, Assistance Publique Hôpitaux de Marseille , Aix Marseille Université , Marseille , France.
authors.forename: Marc
authors.initials: M
authors.lastname: Leone
authors.affiliation: c Unidad Clínica de Cuidados Intensivos , Hospital Universitario Virgen Macarena, Instituto Biomedicina , Sevilla , Spain.
authors.forename: Jose
authors.initials: J
authors.lastname: Garnacho-Montero
authors.affiliation: b Service d'anesthésie et de réanimation, Hôpital Nord, Assistance Publique Hôpitaux de Marseille , Aix Marseille Université , Marseille , France.
authors.forename: Claude
authors.initials: C
authors.lastname: Martin
authors.affiliation: d Trinity College, St James's University Hospital, Trinity Centre for Health Sciences, Multidisciplinary Intensive Care Research Organization (MICRO) , Dublin , Ireland.
authors.forename: Ignacio
authors.initials: I
authors.lastname: Martin-Loeches
mesh_terms: D000368:Aged; D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D003299:Cooperative Behavior; D016638:Critical Illness; D005260:Female; D006090:Gram-Negative Bacteria / Q000302:isolation & purification; D016905:Gram-Negative Bacterial Infections / Q000188:drug therapy / Q000382:microbiology / Q000401:mortality; D006094:Gram-Positive Bacteria / Q000302:isolation & purification; D016908:Gram-Positive Bacterial Infections / Q000188:drug therapy / Q000382:microbiology / Q000401:mortality; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D018805:Sepsis / Q000188:drug therapy* / Q000382:microbiology / Q000401:mortality; D012772:Shock, Septic / Q000188:drug therapy* / Q000382:microbiology / Q000401:mortality
chemical_list: D000900:Anti-Bacterial Agents
keywords: De-escalation; ICU; sepsis; stewardship