De-escalation of antimicrobial therapy is an important component of antimicrobial stewardship. Multi-centered reports of de-escalation practice are limited. We applied a method to quantitatively measure antimicrobial de-escalation utilizing electronic medication administration data based on the spectrum of activity for antimicrobial therapy. We examined the de-escalation prevalence and characterized de-escalation in patients hospitalized with healthcare-associated pneumonia (HCAP).
This was a retrospective cohort study performed in patients hospitalized between 5 and 14 days with HCAP in acute wards in 119 VA facilities. Patients who received antimicrobials for ≥3 days during 2008-2011 were included. The method was applied at the patient level to measure de-escalation on day 4 of hospitalization, and was expressed in aggregate and facility-level proportions. Logistic regression was used to assess variables associated with de-escalation. Odds ratios with 95% confidence intervals were reported.
Among 9319 patients, the de-escalation rate was 28.3% (95% CI 27.4%, 29.2%) which varied six-fold across facilities [median (IQR) facility-level de-escalation rate 29.1% (21.7%, 35.6%)]. Variables independently associated with de-escalation included: initial broad-spectrum therapy [OR 1.5, 95% CI 1.4-1.5 for each 10% increase in spectrum], collection of respiratory tract cultures [OR 1.1, 95% CI 1.0-1.2], and care in higher complexity facilities [OR 1.3, 95% CI 1.1-1.6]. Respiratory tract cultures were collected in 35.3% (95% CI 32.7%, 37.7%) of patients. For the cohort subset admitted in 2011 (n=2366), a patient’s probability of being de-escalated was positively associated with admission to a facility with de-escalation policy (OR 1.4, 95% CI 1.1-1.8, P=0.002) or an IV to PO policy (OR 1.3. 95% CI 1.1-1.5, P=0.012) as determined in a 2012 VA-wide stewardship survey.
De-escalation of therapy was limited and varied substantially across facilities. De-escalation was associated with collection of respiratory tract cultures, receipt of care in facilities with higher levels of complexity, and was performed more frequently in facilities with policies governing de-escalation or IV to PO conversion.
R. Remington, None
C. Caplinger, None
B. Huttner, None
B. Jones, None
M. Samore, None
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