De-escalating Antibiotic Use in the Inpatient Setting: Strategies, Controversies, and Challenges
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Purpose of Review
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.
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.
KeywordsAntibiotic de-escalation Antimicrobial stewardship Resistance
Compliance with Ethical Standards
Conflict of Interest
Drs Markley, Bernard, Bearman, Stevens declares no conflict of interests.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by the author.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 1.Antibiotic/antimicrobial resistance. centers for disease control and prevention. https://www.cdc.gov/drugresistance/. Accessed 7/19/2016, 2016.
- 3.Core elements of hospital antibiotic stewardship programs. http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html#_ENREF_2. Updated 2016. Accessed 7/20, 2016.
- 5.Fridkin S, Baggs J, Fagan R, et al. Vital signs: improving antibiotic use among hospitalized patients. Morb Mortal Wkly Rep. 2014;63(9):194–200.Google Scholar
- 6.Antimicrobial resistance fact sheet. world health organization. http://www.who.int/mediacentre/factsheets/fs194/en/. Accessed 7/19/2016, 2016.
- 7.National action plan for combating antibiotic-resistant bacteria. https://www.whitehouse.gov/sites/default/files/docs/national_action_plan_for_combating_antibotic-resistant_bacteria.pdf. Updated 2015. Accessed 07/22, 2016.
- 8.Antibiotic resistance solutions initiative. centers for disease control and prevention. https://www.cdc.gov/drugresistance/solutions-initiative/index.html. Updated 2016. Accessed 7/22, 2016.
- 9.Barlam TF, Cosgrove SE, Abbo LM, et al. Executive summary: implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis. 2016;62(10):1197–202. doi: 10.1093/cid/ciw217.CrossRefPubMedGoogle Scholar
- 10.• Tabah A, Cotta MO, Garnacho-Montero J, et al. A systematic review of the definitions, determinants, and clinical outcomes of antimicrobial de-escalation in the intensive care unit. Clin Infect Dis. 2016;62(8):1009–17. doi: 10.1093/cid/civ1199. This recent article provides the most up to date review of antimicrobial de-escalation as it pertains to the intensive care unit. The authors address the current evidence base, challenges, and future directions of de-escalation in the ICU. CrossRefPubMedGoogle Scholar
- 11.• Kollef MH, Micek ST. Editorial commentary: antimicrobial de-escalation: what’s in a name? Clin Infect Dis. 2016;62(8):1018–20. doi: 10.1093/cid/civ1201. This editorial provides an expert analysis of the current challenges and future directions of antimicrobial de-escalation. Several key questions are posed that lend valuable insight into the current methodological flaws that are inhibiting the advancement of research in antibiotic de-escalation. CrossRefPubMedGoogle Scholar
- 13.Hummel M, Warga C, Hof H, Hehlmann R, Buchheidt D. Diagnostic yield of blood cultures from antibiotic-naïve and antibiotically treated patients with haematological malignancies and high-risk neutropenia. Scand J Infect Dis. 2009;41(9):650–5. doi: 10.1080/00365540903062150.CrossRefPubMedGoogle Scholar
- 17.•• Masterton RG. Antibiotic de-escalation. Crit Care Clin. 2011;27(1):149–62. doi: 10.1016/j.ccc.2010.09.009. This article provides the most comprehensive review of antimicrobial de-escalation. Anyone interested in developing a basic foundation in de-escalation concepts should read this article. CrossRefPubMedGoogle Scholar
- 19.Singh N, Rogers P, Atwood CW, Wagener MM, Yu VL. Short-course empiric antibiotic therapy for patients with pulmonary infiltrates in the intensive care unit. A proposed solution for indiscriminate antibiotic prescription. Am J Respir Crit Care Med. 2000;162(2):505–11. doi: 10.1164/ajrccm.162.2.9909095.CrossRefPubMedGoogle Scholar
- 29.Schroeder S, Hochreiter M, Koehler T, et al. Procalcitonin (PCT)-guided algorithm reduces length of antibiotic treatment in surgical intensive care patients with severe sepsis: results of a prospective randomized study. Langenbeck's Arch Surg. 2009;394(2):221–6. doi: 10.1007/s00423-008-0432-1.CrossRefGoogle Scholar
- 30.Hochreiter M, Köhler T, Schweiger AM, et al. Procalcitonin to guide duration of antibiotic therapy in intensive are patients: A randomized prospective controlled trial. Crit Care. 2009;13(3). doi: 10.1186/cc7903.
- 32.Prkno A, Wacker C, Brunkhorst FM, Schlattmann P. Procalcitonin-guided therapy in intensive care unit patients with severe sepsis and septic shock–a systematic review and meta-analysis. Crit Care. 2013;17(6). doi: 10.1186/cc13157.
- 33.Jensen JU, Hein L, Lundgren B, et al. Procalcitonin-guided interventions against infections to increase early appropriate antibiotics and improve survival in the intensive care unit: a randomized trial. Crit Care Med. 2011;39(9):2048–58. doi: 10.1097/CCM.0b013e31821e8791.CrossRefPubMedGoogle Scholar
- 36.Carver PL, Lin S, DePestel DD, Newton DW. Impact of mecA gene testing and intervention by infectious disease clinical pharmacists on time to optimal antimicrobial therapy for Staphylococcus aureus bacteremia at a university hospital. J Clin Microbiol. 2008;46(7):2381–3. doi: 10.1128/JCM.00801-08.CrossRefPubMedPubMedCentralGoogle Scholar
- 39.Huang AM, Newton D, Kunapuli A, et al. Impact of rapid organism identification via matrix-assisted laser desorption/ionization time-of-flight combined with antimicrobial stewardship team intervention in adult patients with bacteremia and candidemia. Clin Infect Dis. 2013;57(9):1237–45. doi: 10.1093/cid/cit498.CrossRefPubMedGoogle Scholar
- 40.Holtzman C, Whitney D, Barlam T, Miller NS. Assessment of impact of peptide nucleic acid fluorescence in situ hybridization for rapid identification of coagulase-negative staphylococci in the absence of antimicrobial stewardship intervention. J Clin Microbiol. 2011;49(4):1581–2. doi: 10.1128/JCM.02461-10.CrossRefPubMedPubMedCentralGoogle Scholar
- 44.Get smart: Know when antibiotics work, centers for disease control and prevention. http://www.cdc.gov/getsmart/community/index.html. Updated 2015. Accessed 4/7, 2016.
- 47.2014 Physician Specialty Data Book Center for Workforce Studies. Association of American Medical Colleges. Washington, DC: AAMC; 2014; 1–42. Available at: https://members.aamc.org/eweb/upload/Physician%20Specialty%20Databook%202014.pdf. Accessed 9/9, 2016.
- 48.Chandrasekar PH. Bad news to worse news: 2015 infectious diseases fellowship match results. Clin Infect Dis. 2015;60(9). doi: 10.1093/cid/civ037.
- 51.Tackling drug-resistant infections globally: Final report and recommendations. http://amr-review.org/sites/default/files/160518_Final%20paper_with%20cover.pdf. Updated 2016. Accessed 9/12, 2016.