A systematic review of the definitions, determinants, and clinical outcomes of antimicrobial de-escalation in the intensive care unit

for the Working Group for Antimicrobial Use in the ICU

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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.

Original languageEnglish
Pages (from-to)1009-1017
Number of pages9
JournalClinical Infectious Diseases
Issue number8
Publication statusPublished - 15 Apr 2016
Externally publishedYes


  • de-escalation
  • resistance
  • stewardship
  • streamlining

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