A Systematic Review of the Definitions, Determinants, and Clinical Outcomes of Antimicrobial De-escalation in the Intensive Care Unit

作者：Tabah Alexis^*; Cotta Menino O**ert; Garnacho Montero Jose; Schouten Jeroen; Roberts Jason A; Lipman Jeffrey; Tacey Mark; Timsit Jean Francois; Leone Marc; Zahar Jean Ralph; De Waele Jan J

来源：Clinical Infectious Diseases, 2016, 62(8): 1009-1017.

DOI：10.1093/cid/civ1199

• de-escalation
• stewardship
• streamlining
• resistance

Antimicrobial de-escalation (ADE) is a strategy to reduce the spectrum of antimicrobials and aims to prevent the emergence of bacterial resistance. We present a systematic review describing the definitions, determinants and outcomes associated with ADE. We included 2 randomized controlled trials and 12 cohort studies. There was considerable variability in the definition of ADE. It was more frequently performed in patients with broad-spectrum and/or appropriate antimicrobial therapy (P=.05 to .002), when more agents were used (P=.002), and in the absence of multidrug-resistant pathogens (P<.05). Where investigated, lower or improving severity scores were consistently associated with ADE (P=.04 to <.001). The pooled effect of ADE on mortality is protective (relative risk, 0.68; 95% confidence interval,.52-.88). Because the determinants of ADE are markers of clinical improvement and/or of lower risk of treatment failure this effect on mortality cannot be retained as evidence. None of the studies were designed to investigate the effect of ADE on antimicrobial resistance.

• 出版日期2016-4-15