Clinical, contextual and hospital-level factors associated with escalation and de-escalation of empiric Gram-negative antibiotics among US inpatients.

Autor:	Baghdadi JD; Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA., Goodman KE; Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA., Magder LS; Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA., Heil EL; Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA., Claeys K; Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA., Bork J; Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA., Harris AD; Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA.
Jazyk:	angličtina
Zdroj:	JAC-antimicrobial resistance [JAC Antimicrob Resist] 2023 May 13; Vol. 5 (3), pp. dlad054. Date of Electronic Publication: 2023 May 13 (Print Publication: 2023).
DOI:	10.1093/jacamr/dlad054
Abstrakt:	Background: Empiric Gram-negative antibiotics are frequently changed in response to new information. To inform antibiotic stewardship, we sought to identify predictors of antibiotic changes using information knowable before microbiological test results. Methods: We performed a retrospective cohort study. Survival-time models were used to evaluate clinical factors associated with antibiotic escalation and de-escalation (defined as an increase or decrease, respectively, in the spectrum or number of Gram-negative antibiotics within 5 days of initiation). Spectrum was categorized as narrow, broad, extended or protected. Tjur's D statistic was used to estimate the discriminatory power of groups of variables. Results: In 2019, 2 751 969 patients received empiric Gram-negative antibiotics at 920 study hospitals. Antibiotic escalation occurred in 6.5%, and 49.2% underwent de-escalation; 8.8% were changed to an equivalent regimen. Escalation was more likely when empiric antibiotics were narrow-spectrum (HR 19.0 relative to protected; 95% CI: 17.9-20.1), broad-spectrum (HR 10.3; 95% CI: 9.78-10.9) or extended-spectrum (HR 3.49; 95% CI: 3.30-3.69). Patients with sepsis present on admission (HR 1.94; 95% CI: 1.91-1.96) and urinary tract infection present on admission (HR 1.36; 95% CI: 1.35-1.38) were more likely to undergo antibiotic escalation than patients without these syndromes. De-escalation was more likely with combination therapy (HR 2.62 per additional agent; 95% CI: 2.61-2.63) or narrow-spectrum empiric antibiotics (HR 1.67 relative to protected; 95% CI: 1.65-1.69). Choice of empiric regimen accounted for 51% and 74% of the explained variation in antibiotic escalation and de-escalation, respectively. Conclusions: Empiric Gram-negative antibiotics are frequently de-escalated early in hospitalization, whereas escalation is infrequent. Changes are primarily driven by choice of empiric therapy and presence of infectious syndromes. (© The Author(s) 2023. Published by Oxford University Press on behalf of British Society for Antimicrobial Chemotherapy.)
Databáze:	MEDLINE
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