Safety and feasibility of antibiotic de-escalation in bacteremic pneumonia

Abstract

Faisal A Khasawneh,1 Adnanul Karim,2 Tashfeen Mahmood,3 Subhan Ahmed,4 Sayyed F Jaffri,3 Mansoor Mehmood2 1Section of Infectious Diseases, 2Department of Internal Medicine, Texas Tech University Health Sciences Center, Amarillo, TX, 3Department of Internal Medicine, Deaconess Hospital, Evansville, IN, 4Section of Nephrology, Department of Internal Medicine, University of Oklahoma, Tulsa, OK, USA Background: Antibiotic de-escalation is a potential strategy advocated to conserve the effectiveness of broad-spectrum antibiotics. The aim of this study was to examine the safety and feasibility of antibiotic de-escalation in patients admitted with bacteremic pneumonia. Methods: A retrospective chart review was done for patients with bacteremic pneumonia admitted to Northwest Texas Hospital in Amarillo, TX, USA, during 2008. Antibiotic de-escalation was defined as changing the empiric antibiotic regimen to a culture-directed single agent with a narrower spectrum than the original regimen. Results: Sixty-eight patients were admitted with bacteremic pneumonia. Eight patients were not eligible for de-escalation. Among the 60 patients who were eligible for de-escalation, the treating physicians failed to de-escalate antibiotics in 27 cases (45.0%). Discharge to a long-term care facility predicted failure to de-escalate antibiotics, while an infectious diseases consultation was significantly associated with antibiotic de-escalation. The average daily cost of antibacterial therapy in the de-escalation group was $25.7 compared with $61.6 in the group where de-escalation was not implemented. The difference in mean length of hospital stay and mortality between the two groups was not statistically significant. Conclusion: Antibiotic de-escalation is a safe management strategy but unfortunately is not widely adopted. Although bacterial resistance poses a significant threat and is rising, antimicrobial de-escalation has emerged as a potential intervention that can conserve the effectiveness of broad-spectrum antibiotics without compromising the patient's outcome. This practice is becoming important in the face of slow development of new anti-infective agents. Keywords: bacteremia, antibiotic de-escalation strategy, lung infection