title: De-escalating Antibiotic Use in the Inpatient Setting: Strategies, Controversies, and Challenges.
abstract: OBJECTIVE
  Antibiotic de-escalation (ADE) is widely accepted as an integral strategy to curtail the global antibiotic resistance crisis. However, there is significant uncertainty regarding the ideal ADE strategy and its true impact on antibiotic resistance. Rapid diagnostic testing has the potential to enhance ADE strategies. Herein, we aim to discuss the current strategies, controversies, and challenges of ADE in the inpatient setting.
  
  
  RESULTS
  A consensus definition of ADE remains elusive at this time. Preliminary studies utilizing rapid diagnostic tests including matrix-assisted laser desorption/ionization time of flight (MALDI-TOF), procalcitonin, and other molecular techniques have demonstrated the potential to support ADE strategies. In the absence of evidence-based, highly specific ADE protocols, the likelihood that individual providers will make consistent, often challenging, decisions to de-escalate antibiotic therapy is low. Antimicrobial stewardship programs should support local physicians with ADE and develop innovative ways to integrate ADE into the broader construct of antimicrobial stewardship programs. The evolving field of rapid diagnostics has significant potential to improve ADE strategies, but more research is needed to fully realize this goal.
authors.affiliation: Department of Internal Medicine, Division of Infectious Diseases, Virginia Commonwealth University Medical Center, MCV Campus, VMI Building, Suite 205, 1000 East Marshall Street, P.O. Box 980049, Richmond, VA, 23298-0049, USA. john.markley@vcuhealth.org.
authors.forename: J
authors.initials: J
authors.lastname: Daniel Markley
authors.affiliation: Department of Pharmacy, Virginia Commonwealth University Medical Center, 401 North 12th Street, Richmond, VA, 23298-0042, USA.
authors.forename: Shaina
authors.initials: S
authors.lastname: Bernard
authors.affiliation: Department of Internal Medicine, Division of Infectious Diseases, Virginia Commonwealth University Medical Center, MCV Campus, VMI Building, Suite 205, 1000 East Marshall Street, P.O. Box 980049, Richmond, VA, 23298-0049, USA.
authors.forename: Gonzalo
authors.initials: G
authors.lastname: Bearman
authors.affiliation: Department of Internal Medicine, Division of Infectious Diseases, Virginia Commonwealth University Medical Center, MCV Campus, VMI Building, Suite 205, 1000 East Marshall Street, P.O. Box 980049, Richmond, VA, 23298-0049, USA.
authors.forename: Michael P
authors.initials: MP
authors.lastname: Stevens
keywords: Antibiotic de-escalation; Antimicrobial stewardship; Resistance