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

De Bus, Liesbet ; Depuydt, Pieter ; Steen, Johan ; Dhaese, Sofie ; De Smet, Ken ; Tabah, Alexis ; Akova, Murat ; Cotta, Menino Osbert ; De Pascale, Gennaro and Dimopoulos, George , et al. (2020) In Intensive Care Medicine 46(7). p.1404-1417
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... (More)

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.

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LU orcid
author collaboration
organization
publishing date
type
Contribution to journal
publication status
published
subject
in
Intensive Care Medicine
volume
46
issue
7
pages
14 pages
publisher
Springer
external identifiers
  • scopus:85086169918
  • pmid:32519003
ISSN
0342-4642
DOI
10.1007/s00134-020-06111-5
language
English
LU publication?
yes
id
b95f86b4-2865-45ff-898e-2e2d6af85457
date added to LUP
2020-06-15 10:13:39
date last changed
2024-04-17 10:29:51
@article{b95f86b4-2865-45ff-898e-2e2d6af85457,
  abstract     = {{<p>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.</p><p>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.</p><p>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).</p><p>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.</p>}},
  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, Jeffrey and Ostermann, Marlies and Paiva, José-Artur and Schouten, Jeroen and Sjövall, Fredrik and Timsit, Jean-François and Roberts, Jason A and Zahar, Jean-Ralph and Zand, Farid and Zirpe, Kapil and De Waele, Jan J}},
  issn         = {{0342-4642}},
  language     = {{eng}},
  number       = {{7}},
  pages        = {{1404--1417}},
  publisher    = {{Springer}},
  series       = {{Intensive Care Medicine}},
  title        = {{Antimicrobial de-escalation in the critically ill patient and assessment of clinical cure : the DIANA study}},
  url          = {{http://dx.doi.org/10.1007/s00134-020-06111-5}},
  doi          = {{10.1007/s00134-020-06111-5}},
  volume       = {{46}},
  year         = {{2020}},
}