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Antimicrobial de-escalation in the critically ill patient and assessment of clinical cure : the DIANA study

Liesbet De Bus (UGent) , Pieter Depuydt (UGent) , Johan Steen (UGent) , Sofie Dhaese, Ken De Smet, Alexis Tabah, Murat Akova, Menino Osbert Cotta, Gennaro De Pascale, George Dimopoulos, et al.
(2020) INTENSIVE CARE MEDICINE. 46(7). p.1404-1417
Author
Organization
Abstract
Purpose The DIANA study aimed to evaluate how often antimicrobial de-escalation (ADE) of empirical treatment is performed in the intensive care unit (ICU) and to estimate the effect of ADE on clinical cure on day 7 following treatment initiation. Methods Adult ICU patients receiving empirical antimicrobial therapy for bacterial infection were studied in a prospective observational study from October 2016 until May 2018. ADE was defined as (1) discontinuation of an antimicrobial in case of empirical combination therapy or (2) replacement of an antimicrobial with the intention to narrow the antimicrobial spectrum, within the first 3 days of therapy. Inverse probability (IP) weighting was used to account for time-varying confounding when estimating the effect of ADE on clinical cure. Results Overall, 1495 patients from 152 ICUs in 28 countries were studied. Combination therapy was prescribed in 50%, and carbapenems were prescribed in 26% of patients. Empirical therapy underwent ADE, no change and change other than ADE within the first 3 days in 16%, 63% and 22%, respectively. Unadjusted mortality at day 28 was 15.8% in the ADE cohort and 19.4% in patients with no change [p = 0.27; RR 0.83 (95% CI 0.60-1.14)]. The IP-weighted relative risk estimate for clinical cure comparing ADE with no-ADE patients (no change or change other than ADE) was 1.37 (95% CI 1.14-1.64). Conclusion ADE was infrequently applied in critically ill-infected patients. The observational effect estimate on clinical cure suggested no deleterious impact of ADE compared to no-ADE. However, residual confounding is likely.
Keywords
Critical Care and Intensive Care Medicine, VENTILATOR-ASSOCIATED PNEUMONIA, ANTIBIOTIC-THERAPY, SEVERE SEPSIS, STEWARDSHIP PROGRAM, DELPHI METHOD, SEPTIC SHOCK, BETA-LACTAM, R-PACKAGE, GUIDELINES, EPIDEMIOLOGY, Antimicrobial de-escalation, Intensive care unit, Bacterial infection, Empirical therapy, Clinical cure

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MLA
De Bus, Liesbet, et al. “Antimicrobial De-Escalation in the Critically Ill Patient and Assessment of Clinical Cure : The DIANA Study.” INTENSIVE CARE MEDICINE, vol. 46, no. 7, 2020, pp. 1404–17, doi:10.1007/s00134-020-06111-5.
APA
De Bus, L., Depuydt, P., Steen, J., Dhaese, S., De Smet, K., Tabah, A., … De Waele, J. (2020). Antimicrobial de-escalation in the critically ill patient and assessment of clinical cure : the DIANA study. INTENSIVE CARE MEDICINE, 46(7), 1404–1417. https://doi.org/10.1007/s00134-020-06111-5
Chicago author-date
De Bus, Liesbet, Pieter Depuydt, Johan Steen, Sofie Dhaese, Ken De Smet, Alexis Tabah, Murat Akova, et al. 2020. “Antimicrobial De-Escalation in the Critically Ill Patient and Assessment of Clinical Cure : The DIANA Study.” INTENSIVE CARE MEDICINE 46 (7): 1404–17. https://doi.org/10.1007/s00134-020-06111-5.
Chicago author-date (all authors)
De Bus, Liesbet, Pieter Depuydt, Johan Steen, Sofie Dhaese, Ken De Smet, Alexis Tabah, Murat Akova, Menino Osbert Cotta, Gennaro De Pascale, George Dimopoulos, Shigeki Fujitani, Jose Garnacho-Montero, Marc Leone, Jerey Lipman, Marlies Ostermann, Jose-Artur Paiva, Jeroen Schouten, Fredrik Sjovall, Jean-Francois Timsit, Jason A. Roberts, Jean-Ralph Zahar, Farid Zand, Kapil Zirpe, and Jan De Waele. 2020. “Antimicrobial De-Escalation in the Critically Ill Patient and Assessment of Clinical Cure : The DIANA Study.” INTENSIVE CARE MEDICINE 46 (7): 1404–1417. doi:10.1007/s00134-020-06111-5.
Vancouver
1.
De Bus L, Depuydt P, Steen J, Dhaese S, De Smet K, Tabah A, et al. Antimicrobial de-escalation in the critically ill patient and assessment of clinical cure : the DIANA study. INTENSIVE CARE MEDICINE. 2020;46(7):1404–17.
IEEE
[1]
L. De Bus et al., “Antimicrobial de-escalation in the critically ill patient and assessment of clinical cure : the DIANA study,” INTENSIVE CARE MEDICINE, vol. 46, no. 7, pp. 1404–1417, 2020.
@article{8672662,
  abstract     = {{Purpose The DIANA study aimed to evaluate how often antimicrobial de-escalation (ADE) of empirical treatment is performed in the intensive care unit (ICU) and to estimate the effect of ADE on clinical cure on day 7 following treatment initiation. Methods Adult ICU patients receiving empirical antimicrobial therapy for bacterial infection were studied in a prospective observational study from October 2016 until May 2018. ADE was defined as (1) discontinuation of an antimicrobial in case of empirical combination therapy or (2) replacement of an antimicrobial with the intention to narrow the antimicrobial spectrum, within the first 3 days of therapy. Inverse probability (IP) weighting was used to account for time-varying confounding when estimating the effect of ADE on clinical cure. Results Overall, 1495 patients from 152 ICUs in 28 countries were studied. Combination therapy was prescribed in 50%, and carbapenems were prescribed in 26% of patients. Empirical therapy underwent ADE, no change and change other than ADE within the first 3 days in 16%, 63% and 22%, respectively. Unadjusted mortality at day 28 was 15.8% in the ADE cohort and 19.4% in patients with no change [p = 0.27; RR 0.83 (95% CI 0.60-1.14)]. The IP-weighted relative risk estimate for clinical cure comparing ADE with no-ADE patients (no change or change other than ADE) was 1.37 (95% CI 1.14-1.64). Conclusion ADE was infrequently applied in critically ill-infected patients. The observational effect estimate on clinical cure suggested no deleterious impact of ADE compared to no-ADE. However, residual confounding is likely.}},
  author       = {{De Bus, Liesbet and Depuydt, Pieter and Steen, Johan and Dhaese, Sofie and De Smet, Ken and Tabah, Alexis and Akova, Murat and Cotta, Menino Osbert and De Pascale, Gennaro and Dimopoulos, George and Fujitani, Shigeki and Garnacho-Montero, Jose and Leone, Marc and Lipman, Jerey and Ostermann, Marlies and Paiva, Jose-Artur and Schouten, Jeroen and Sjovall, Fredrik and Timsit, Jean-Francois and Roberts, Jason A. and Zahar, Jean-Ralph and Zand, Farid and Zirpe, Kapil and De Waele, Jan}},
  issn         = {{0342-4642}},
  journal      = {{INTENSIVE CARE MEDICINE}},
  keywords     = {{Critical Care and Intensive Care Medicine,VENTILATOR-ASSOCIATED PNEUMONIA,ANTIBIOTIC-THERAPY,SEVERE SEPSIS,STEWARDSHIP PROGRAM,DELPHI METHOD,SEPTIC SHOCK,BETA-LACTAM,R-PACKAGE,GUIDELINES,EPIDEMIOLOGY,Antimicrobial de-escalation,Intensive care unit,Bacterial infection,Empirical therapy,Clinical cure}},
  language     = {{eng}},
  number       = {{7}},
  pages        = {{1404--1417}},
  title        = {{Antimicrobial de-escalation in the critically ill patient and assessment of clinical cure : the DIANA study}},
  url          = {{http://doi.org/10.1007/s00134-020-06111-5}},
  volume       = {{46}},
  year         = {{2020}},
}
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