This study reveals the current practices and potential barriers of antibiotic de-escalation (ADE) in Gram-negative bacteremia infections, emphasizing the significant impact of hematologic malignancies and ESBL-positive strains on ADE practices. The findings provide important insights for optimizing antimicrobial stewardship strategies.
Literature Overview
Published in the journal Antibiotics, this study titled 'The Analysis of Missed Antibiotic De-Escalation Opportunities in Gram-Negative Bloodstream Infections' reviews a multi-center retrospective cohort study examining missed antibiotic de-escalation (ADE) opportunities in Gram-negative bloodstream infections. The study included 273 episodes of bacteremia, where only 43 cases underwent ADE while 101 cases presented missed ADE opportunities. It analyzed clinical characteristics associated with ADE implementation and evaluated variables linked to missed ADE opportunities.
Background Knowledge
Antibiotic de-escalation (ADE) is a clinical strategy aiming to replace initial broad-spectrum antibiotics with narrower-spectrum alternatives after obtaining microbiological culture results, thereby reducing antimicrobial resistance, toxicity, and costs. While multiple studies support ADE's safety in severe infections, its clinical application remains limited, particularly among patients with multidrug resistance or immunosuppression. This study focuses on bacteremia patients from two Turkish medical centers, investigating ADE implementation barriers with special attention to hematologic malignancies and ESBL-producing strains. It underscores the importance of antimicrobial stewardship programs in clinical decision-making and the necessity to improve physician ADE practices.
Research Methods and Experiments
The study employed a retrospective, dual-center cohort design, enrolling adult patients diagnosed with Gram-negative bloodstream infections at Koç University Hospital and American Hospital between January 2018 and June 2019. ADE was defined as switching to a narrower-spectrum antibiotic or discontinuing one component of combination therapy within seven days of bacteremia onset. Patients with inappropriate empirical antibiotics, death within three days of bacteremia, or ADE implementation beyond seven days were excluded. Multivariate analysis assessed predictors of ADE implementation and missed opportunities.
Key Conclusions and Perspectives
Research Significance and Prospects
This research highlights the need for antimicrobial stewardship programs to prioritize ADE practice improvements in high-prevalence multidrug-resistant Gram-negative pathogen regions, specifically for patients with hematologic malignancies and ESBL infections. Future studies should evaluate ADE safety across diverse clinical environments and validate standardized stewardship strategies to promote personalized antibiotic use.
Conclusion
This study systematically analyzes ADE implementation in Gram-negative bloodstream infections, identifying critical barriers to ADE adoption. Hematologic malignancies and ESBL-producing infections significantly reduce ADE implementation likelihood, while Escherichia coli infections and empirical ertapenem use facilitate ADE adoption. Although the ADE group demonstrated lower mortality rates, multivariate analysis showed no statistical significance, indicating clinical stability may influence ADE decisions. Findings emphasize the necessity for antimicrobial stewardship programs to enhance clinician education and feedback to improve ADE practices, particularly in multidrug-resistant environments. Future research should further assess ADE safety and efficacy across patient subgroups to advance personalized antimicrobial treatment strategies.
