The impact of antimicrobial de-escalation therapy in culture-negative pneumonia: a systematic review and meta-analysis
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Background/Aims: Antimicrobial de-escalation (ADE) remains a challenging strategy in the treatment of pneumonia. We investigated the outcomes of ADE as measured by mortality and duration of the use of antibiotics in patients with culture- negative pneumonia. Methods: We performed a systematic review and meta-analysis in accordance with PRISMA guidelines. The primary outcome was inpatient mortality. Results: We examined six studies comprising 11,933 subjects, of whom 1,152 received ADE. Overall, the ADE strategy was associated with a statistically lower risk of in-hospital mortality compared with non-ADE (risk ratio [RR] = 0.60, 95% confidence interval [CI] = 0.38 to 0.93). Although substantial heterogeneity was found among the included studies (I2 = 66%), a meta-regression analysis could not reveal plausible sources of heterogeneity. And ADE was associated with a shorter duration of total and initial antibiotic therapies and total length of hospital stay compared with non-ADE. Conclusions: Our findings suggest that ADE seems to be significantly associated with better clinical outcomes compared with non-ADE. Caution is demanded when interpreting data of this study because of substantial between-study heterogeneity.
Abstract
Background/Aims: Antimicrobial de-escalation (ADE) remains a challenging strategy in the treatment of pneumonia. We investigated the outcomes of ADE as measured by mortality and duration of the use of antibiotics in patients with culture- negative pneumonia. Methods: We performed a systematic review and meta-analysis in accordance with PRISMA guidelines. The primary outcome was inpatient mortality. Results: We examined six studies comprising 11,933 subjects, of whom 1,152 received ADE. Overall, the ADE strategy was associated with a statistically lower risk of in-hospital mortality compared with non-ADE (risk ratio [RR] = 0.60, 95% confidence interval [CI] = 0.38 to 0.93). Although substantial heterogeneity was found among the included studies (I2 = 66%), a meta-regression analysis could not reveal plausible sources of heterogeneity. And ADE was associated with a shorter duration of total and initial antibiotic therapies and total length of hospital stay compared with non-ADE. Conclusions: Our findings suggest that ADE seems to be significantly associated with better clinical outcomes compared with non-ADE. Caution is demanded when interpreting data of this study because of substantial between-study heterogeneity.
참고문헌 (24)
- Kalil AC, "Management of adults with hospital-acquired and ventilator-associated pneumonia : 2016 clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society", Clin Infect Dis, 63, pp.e61~e111 (2016)
- Bell BG, "A systematic review and meta-analysis of the effects of antibiotic consumption on antibiotic resistance", BMC Infect Dis, 14, pp.13~ (2014)
- De Bus L, "Antimicrobial de-escalation in the critically ill patient and assessment of clinical cure: the DIANA study", Intensive Care Med, 46, pp.1404~1417 (2020)
- Garnacho-Montero J, "De-escalation of empirical therapy is associated with lower mortality in patients with severe sepsis and septic shock", Intensive Care Med, 40, pp.32~40 (2014)
- Rello J, "De-escalation therapy in ventilator-associated pneumonia", Crit Care Med, 32, pp.2183~2190 (2004)
- Kollef MH, "Clinical characteristics and treatment patterns among patients with ventilator-associated pneumonia", Chest, 129, pp.1210~1218 (2006)
- de Prost N, "Unrevealing culture-negative severe sepsis", Crit Care, 17, pp.1001~ (2013)
- Jain S, "CDC EPIC Study Team. Community-acquired pneumonia requiring hospitalization among U.S. adults", N Engl J Med, 373, pp.415~427 (2015)
- Phua J, "Characteristics and outcomes of culture-negative versus culture-positive severe sepsis", Crit Care, 17, pp.R202~ (2013)
- Labelle AJ, "A comparison of culture-positive and culture-negative health-care-associated pneumonia", Chest, 137, pp.1130~1137 (2010)
- Tabah A, "A systematic review of the definitions, determinants, and clinical outcomes of antimicrobial de-escalation in the intensive care unit", Clin Infect Dis, 62, pp.1009~1017 (2016)
- Moher D, "Preferred reporting items for systematic reviews and meta-analyses : the PRISMA statement", Ann Intern Med, 151, pp.264~269 (2009)
- Sterne JA, "ROBINS-I : a tool for assessing risk of bias in non-randomised studies of interventions", BMJ, 355, pp.i4919~ (2016)
- Higgins JP, "Measuring inconsistency in meta-analyses", BMJ, 327, pp.557~560 (2003)
- Cowley MC, "Outcomes associated with de-escalating therapy for methicillin-resistant staphylococcus aureus in culture-negative nosocomial pneumonia", Chest, 155, pp.53~59 (2019)
- Deshpande A, "De-escalation of empiric antibiotics following negative cultures in hospitalized patients with pneumonia : rates and outcomes", Clin Infect Dis, 72, pp.1314~1322 (2021)
- Joung MK, "Impact of de-escalation therapy on clinical outcomes for intensive care unit-acquired pneumonia", Crit Care, 15, pp.R79~ (2011)
- Kown BS, "Safety of antimicrobial de-escalation for culture-negative severe pneumonia", J Crit Care, 54, pp.14~19 (2019)
- Raman K, "Early antibiotic discontinuation in patients with clinically suspected ventilator-associated pneumonia and negative quantitative bronchoscopy cultures", Crit Care Med, 41, pp.1656~1663 (2013)
- Schlueter M, "Practice patterns for antibiotic de-escalation in culture-negative healthcare-associated pneumonia", Infection, 38, pp.357~362 (2010)
- Metlay JP, "Diagnosis and treatment of adults with community-acquired pneumonia. an official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America", Am J Respir Crit Care Med, 200, pp.e45~e67 (2019)
- Dean NC, "Impact of an electronic clinical decision support tool for emergency department patients with pneumonia", Ann Emerg Med, 66, pp.511~520 (2015)
- Kaki R, "Impact of antimicrobial stewardship in critical care : a systematic review", J Antimicrob Chemother, 66, pp.1223~1230 (2011)
- Webb BJ, "Broad-spectrum antibiotic use and poor outcomes in community-onset pneumonia : a cohort study", Eur Respir J, 54, pp.1900057~ (2019)