De-escalation therapy: 1-year experience in a general intensive care unit

Introduction

First-line choice of antibiotic treatment is an important issue for successful outcome in surgical and trauma patients. De-escalation strategy aims to improve the first choice of antibiotic therapy, to improve outcome and to save money.

Setting

A general ICU, 17 beds, annual admission approximately 800 patients.

Objective

To compare rates of success and failure of the empiric treatment of patients with usually prescribed antibiotics and the use of carbapenems with subsequent de-escalation.

Method

Taking data from flow-charts, we determined the most frequently prescribed empiric antibiotics in our ICU during 2002 and calculated the rates of success and failure of the treatment. We considered the failure an inadequate antibiotic therapy. As shown in Table 1, there were two regimens used in 2002. The use of mefoxin was quite disappointing with only a 30% success rate. When other empiric antibiotic, or combination of antibiotics were used the rate of success was slightly below 50%. This can be partly explained with the high rate of surgical complications. In 2003–2004 we accepted for use the de-escalation strategy. Starting empiric carbapenems (tienam in 106 patients, meronem in 31 patients), we obtained samples for the microbiological laboratory from the sites of suspected infection. After receiving positive results we de-escalated antibiotic therapy according to susceptibility. The rate of success increased 11%, and the cases of inadequate empiric therapy fell to 4.4% of cases. Mortality rate decreased from 31% to 13%.

Table 1

Conclusions

Introducing de-escalation strategy into our clinical practice showed promising results. The percentage of cases of treatment failure (inadequate empiric antibiotic therapy) and the mortality rate decreased significantly. We need a longer period to confirm these result, as well as to analyze cost-effectiveness.