Gutiérrez-Pizarraya Antonio, Leone Marc, Garnacho-Montero Jose, Martin Claude, Martin-Loeches Ignacio
a Department of Intensive Care Medicine , Instituto de Biomedicina de Sevilla, IBIS/Hospitales Universitarios Virgen Macarena -Virgen del Rocío /CSIC/Universidad de Sevilla , Sevilla , Spain.
b Service d'anesthésie et de réanimation, Hôpital Nord, Assistance Publique Hôpitaux de Marseille , Aix Marseille Université , Marseille , France.
Expert Rev Clin Pharmacol. 2017 Apr;10(4):457-465. doi: 10.1080/17512433.2017.1293520. Epub 2017 Mar 2.
There is a concern to conduct de-escalation in very sick patients.
To determine if de-escalation is feasible in ICU settings.
We performed a metaanalysis of published studies conducted comparing de-escalation (defined by withdrawal of at least one antimicrobial empirically prescribed, switch to a new antimicrobial with narrower spectrum and withdrawal of at least one antimicrobial plus change of another drug to a new one with narrower spectrum) in non-immunocompromised patients with sepsis admitted to ICU.
Eight hundred and seventeen patients with severe sepsis or septic shock were evaluated. De-escalation was applied in 274 patients (33.5%). We found no differences in hospital long of stay between de-escalation group compared to those who did not receive it. We also found significant lower hospital mortality in de-escalation group as compared with no modification group in front of the others (25.9 vs. 43.1%; p < 0.001). Taking into account the etiology of infection, in both gram negative and gram positives microorganisms, de-escalation strategy was assessed as a good prognosis factor for mortality in the adjusted multivariate analysis (OR 0.41; 95% CI 0.22-0.74 and OR 0.33; 95% CI 0.15-0.70 respectively) whereas SOFA score along with age were found as a factors independently associated with a worse clinical outcome (OR 1.23; 95% CI 1.12-1.35 and OR 1.02; 95% CI 1.01-1.04 respectively).
In our study there was an independent association of de-escalation and decrease mortality rate.
对于病情严重的患者，人们关注实施降阶梯治疗。
确定在重症监护病房（ICU）环境中降阶梯治疗是否可行。
我们对已发表的研究进行了荟萃分析，这些研究比较了入住ICU的非免疫功能低下脓毒症患者的降阶梯治疗（定义为至少停用一种经验性使用的抗菌药物、换用谱更窄的新抗菌药物以及至少停用一种抗菌药物并将另一种药物换用谱更窄的新药物）。
对817例严重脓毒症或脓毒性休克患者进行了评估。274例患者（33.5%）接受了降阶梯治疗。我们发现降阶梯治疗组与未接受降阶梯治疗组相比，住院时间没有差异。我们还发现，与其他未进行调整的组相比，降阶梯治疗组的医院死亡率显著降低（25.9%对43.1%；P<0.001）。考虑到感染的病因，在革兰阴性菌和革兰阳性菌中，在调整后的多变量分析中，降阶梯治疗策略被评估为死亡率的良好预后因素（分别为OR 0.41；95%CI 0.22 - 0.74和OR 0.33；95%CI 0.15 - 0.70），而序贯器官衰竭评估（SOFA）评分和年龄被发现是与更差临床结局独立相关的因素（分别为OR 1.23；95%CI 1.12 - 1.35和OR 1.02；95%CI 1.01 - 1.04）。
在我们的研究中，降阶梯治疗与降低死亡率存在独立关联。
