Battula Vasudha, Krupanandan Ravi Kumar, Nambi P Senthur, Ramachandran Bala
Department of Pediatric Critical Care, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India.
Department of Pediatric Infectious Diseases, Kanchi Kamakoti CHILDS Trust Hospital and The CHILDS Trust Medical Research Foundation, Chennai, India.
Front Pediatr. 2021 Mar 8;9:640857. doi: 10.3389/fped.2021.640857. eCollection 2021.
De-escalation is the key to balance judicious antibiotic usage for life-threatening infections and reducing the emergence of antibiotic resistance caused by antibiotic overuse. Robust evidence is lacking regarding the safety of antibiotic de-escalation in culture negative sepsis. Children admitted to the PICU during the first 6 months of 2019 with suspected infection were included. Based on the clinical condition, cultures and septic markers, antibiotics were de-escalated or continued at 48-72 h. Outcome data like worsening of primary infection, acquisition of hospital acquired infection, level of ICU support and mortality were captured. Among the 360 admissions, 247 (68.6%) children received antibiotics. After excluding 92 children, 155 children with 162 episodes of sepsis were included in the study. Thirty four episodes were not eligible for de-escalation. Among the eligible group of 128 episodes, antibiotics were de-escalated in 95 (74.2%) and continued in 33 (25.8%). The primary infection worsened in 5 (5.2%) children in the de-escalation group and in 1 (3%) in non de-escalation group [Hazard ratio: 2.12 (95%CI: 0.39-11.46)]. There were no significant differences in rates of hospital acquired infection, mortality or length of ICU stay amongst the groups. Blood cultures and assessment of clinical recovery played a major role in de-escalation of antibiotics and the clinician's hesitation to de-escalate in critically ill culture negative children was the main reason for not de-escalating among eligible children. Antibiotic de-escalation appears to be a safe strategy to apply in criticallly ill children, even in those with negative cultures.
降阶梯治疗是平衡危及生命感染的合理抗生素使用与减少抗生素过度使用导致的抗生素耐药性出现的关键。关于培养阴性脓毒症中抗生素降阶梯治疗的安全性，目前缺乏有力证据。纳入了2019年上半年因疑似感染入住儿科重症监护病房（PICU）的儿童。根据临床状况、培养结果和脓毒症标志物，在48 - 72小时时对抗生素进行降阶梯或继续使用。记录了如原发性感染恶化、获得医院获得性感染、ICU支持水平和死亡率等结局数据。在360例入院病例中，247例（68.6%）儿童接受了抗生素治疗。排除92例儿童后，155例患有162次脓毒症发作的儿童被纳入研究。34次发作不符合降阶梯治疗标准。在符合条件的128次发作组中，95次（74.2%）抗生素进行了降阶梯治疗，33次（25.8%）继续使用。降阶梯治疗组中有5例（5.2%）儿童原发性感染恶化，非降阶梯治疗组中有1例（3%）[风险比：2.12（95%置信区间：0.39 - 11.46）]。各组之间在医院获得性感染率、死亡率或ICU住院时间方面没有显著差异。血培养和临床恢复评估在抗生素降阶梯治疗中起主要作用，而临床医生在重症培养阴性儿童中对降阶梯治疗的犹豫是符合条件儿童未进行降阶梯治疗的主要原因。抗生素降阶梯治疗似乎是一种适用于重症儿童的安全策略，即使是那些培养结果为阴性的儿童。
