Antimicrobial De-escalation Rates following Positive Cultures in Pneumonia. (4th October 2017) - Deshpande, Abhishek
Abstract: Background: For patients at risk for multidrug resistant organisms, the recommended empirical therapy includes 1 agent against methicillin-resistant S. aureus (MRSA) and 1 against Pseudomonas . Guidelines recommend de-escalation following positive cultures but it is unclear how often this recommendation is followed. We assessed the rate of de-escalation among a large cohort of pneumonia patients. Methods: We included adults admitted with pneumonia 2010- 2015 to 168 US hospitals if they had blood/respiratory cultures obtained and received empiric vancomycin together with an antipseudomonal drug other than a quinolone by hospital day 1. Patients who died or were discharged before hospital day 4 were excluded. De-escalation for a cultured Gram-positive organism (which should not require antipseudomonal coverage) was defined as discontinuation of the antipseudomonal drug and for a Gram-negative organism (which should not require vancomycin) as discontinuation of vancomycin by hospital day 4, while continuing another antibiotic in either case. We compared de-escalation rates following positive cultures to those following negative cultures. Results: We identified 29, 333 patients who met inclusion criteria. Of the patients with positive cultures (4415), 53% had a Gram-positive and 47% a Gram-negative organism. Antipseudomonals were stopped by hospital day 4 more often following identification of a Gram-positive organism than following negative cultures (44% vs. 26%, P < 0.001). Similarly, vancomycin was stopped by hospital day 4 more often after a Gram-negative organism was cultured than when no organism was identified (66% vs. 49%, P < 0.001). Conclusion: In a large US inpatient database, de-escalation was more common following positive cultures than negative cultures. De-escalation was most common following growth of Gram-negative organisms. There remains substantial opportunity for improvement in antibiotic de-escalation. Disclosures: S. S. Richter, bioMerieux: Investigator, Research support; BD Diagnostics: Investigator, Research support; Roche: Investigator, Research support; BioFire: Investigator, Research support; OpGen: Investigator, Research support; S. Haessler, AHRQ: Investigator, Research grant; P. C. Yu, AHRQ: Investigator, Research grant; M. D. Zilberberg, Astellas: Consultant and Investigator, Research support; Merck: Consultant and Investigator, Research support; The Medicines Company: Consultant and Investigator, Research support; Shionogi: Consultant and Investigator, Research support; Pfizer: Consultant and Investigator, Research support; Theravance: Consultant and Investigator, Research support; J&J: Shareholder, Shareholder; M. Rothberg, AHRQ: Investigator, Research grant