Garnacho-Montero Jose, Escoresca-Ortega Ana, Fernández-Delgado Esperanza
aCritical Care and Emergency Department, Intensive Care Unit, Virgen del Rocío University Hospital bInstituto de Biomedicina de Sevilla (IBIS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla cSpanish Network for Research in Infectious Disease (REIPI), Virgen del Rocío University Hospital, Sevilla, Spain.
Curr Opin Infect Dis. 2015 Apr;28(2):193-8. doi: 10.1097/QCO.0000000000000141.
An antimicrobial policy consisting of the initial use of wide-spectrum antimicrobials followed by a reassessment of treatment when culture results are available is termed de-escalation therapy. Our aim is to examine the safety and feasibility of antibiotic de-escalation in critically ill patients providing practical tips about how to accomplish this strategy in the critical care setting.
Numerous studies have assessed the rates of de-escalation therapy (range from 10 to 60%) in patients with severe sepsis or ventilator-associated pneumonia as well as the factors associated with de-escalation. De-escalation generally refers to a reduction in the spectrum of administered antibiotics through the discontinuation of antibiotics or switching to an agent with a narrower spectrum. Diverse studies have identified the adequacy of initial therapy as a factor independently associated with de-escalation. Negative impact on different outcome measures has not been reported in the observational studies. Two randomized clinical trials have evaluated this strategy in patients with ventilator-associated pneumonia or severe sepsis. These trials alert us about the possibility that this strategy may be linked to a higher rate of reinfections but without an impact on mortality.
Antibiotic de-escalation is a well tolerated management strategy in critically ill patients but unfortunately is not widely adopted.
一种抗菌策略，即初始使用广谱抗菌药物，待培养结果出来后重新评估治疗方案，这被称为降阶梯治疗。我们的目的是研究在重症患者中进行抗生素降阶梯治疗的安全性和可行性，并提供在重症监护环境中实施该策略的实用技巧。
众多研究评估了严重脓毒症或呼吸机相关性肺炎患者的降阶梯治疗率（范围为10%至60%）以及与降阶梯相关的因素。降阶梯通常是指通过停用抗生素或换用谱较窄的药物来缩小所使用抗生素的谱。不同的研究已确定初始治疗的充分性是与降阶梯独立相关的一个因素。观察性研究中未报告对不同结局指标的负面影响。两项随机临床试验在呼吸机相关性肺炎或严重脓毒症患者中评估了该策略。这些试验提醒我们，该策略可能与再感染率较高有关，但对死亡率无影响。
抗生素降阶梯治疗在重症患者中是一种耐受性良好的管理策略，但遗憾的是未被广泛采用。
