Background: Antimicrobial de-escalation refers to starting the antimicrobial treatment with broad-spectrum antibiotics, followed by narrowing the drug spectrum according to culture results. The present study evaluated the effect of de-escalation on ventilator-associated pneumonia (VAP) in trauma patients.
Methods: This retrospective study was conducted on trauma patients with VAP, who received de-escalation therapy (de-escalation group) or non-de-escalation therapy (non-de-escalation group). Propensity score matching method was used to balance the baseline characteristics between both groups. The 28-day mortality, length of hospitalization and Intensive Care Unit stay, and expense of antibiotics and hospitalization between both groups were compared. Multivariable analysis explored the factors that influenced the 28-day mortality and implementation of de-escalation.
Results: Among the 156 patients, 62 patients received de-escalation therapy and 94 patients received non-de-escalation therapy. No significant difference was observed in 28-day mortality between both groups (28.6% vs. 23.8%, P = 0.620). The duration of antibiotics treatment in the de-escalation group was shorter than that in the non-de-escalation group (11 [8-13] vs. 14 [8-19] days, P = 0.045). The expenses of antibiotics and hospitalization in de-escalation group were significantly lower than that in the non-de-escalation group (6430 ± 2730 vs. 7618 ± 2568 RMB Yuan, P = 0.043 and 19,173 ± 16,861 vs. 24,184 ± 12,039 RMB Yuan, P = 0.024, respectively). Multivariate analysis showed that high Acute Physiology and Chronic Health Evaluation II (APACHE II) score, high injury severity score, multi-drug resistant (MDR) infection, and inappropriate initial antibiotics were associated with patients' 28-day mortality, while high APACHE II score, MDR infection and inappropriate initial antibiotics were independent factors that prevented the implementation of de-escalation.
Conclusions: De-escalation strategy in the treatment of trauma patients with VAP could reduce the duration of antibiotics treatments and expense of hospitalization, without increasing the 28-day mortality and MDR infection.
创伤患者呼吸机相关性肺炎的抗生素降阶梯治疗：一项基于倾向得分匹配法的回顾性研究摘要背景：抗生素降阶梯治疗是采用广谱抗生素进行起始抗感染治疗，随后根据细菌学培养结果针对特定病原菌改用窄谱抗生素抗感染治疗。本研究旨在评估抗生素降阶梯治疗对创伤合并呼吸机相关性肺炎患者的影响。 方法：该回顾性研究纳入创伤合并呼吸机相关性肺炎的患者，在诊治过程中采用抗生素降阶梯治疗（降阶梯治疗组）或未采用抗生素降阶梯治疗（非降阶梯治疗组）。采用倾向得分匹配法平衡两组患者基线特征，比较两组患者的28天死亡率、住院和住重症监护病房时间，以及抗生素使用费用和住院总费用，并采用多元分析探索影响患者28天死亡率和抗生素降阶梯治疗的危险因素。 结果：共有156例患者纳入研究，其中62例接受抗生素降阶梯治疗，94例未接受抗生素降阶梯治疗。两组患者的28天死亡率未见明显差异（28.6% vs. 23.8%, P=0.620）。降阶梯治疗组患者的抗生素使用时间短于非降阶梯治疗组（11 (8–13) vs. 14 (8–19) days, P=0.045），并且降阶梯治疗组患者的抗生素使用费用和住院总费用低于非降阶梯治疗组（6430 ± 2730 vs. 7618 ± 2568 元人民币, P = 0.043 and 19,173 ± 16,861 vs. 24,184 ± 12,039 元人民币, P = 0.024）。多元分析提示患者的高APACHE II评分、高ISS评分、多重耐药菌感染和不恰当的起始抗感染治疗与患者的28天死亡率相关，而高APACHE II评分、多重耐药菌感染和不恰当的起始抗感染治疗是影响抗生素降阶梯的独立危险因素。 结论：采用抗生素降阶梯策略治疗创伤合并呼吸机相关性肺炎患者，可以减少抗生素的使用时间和患者住院总费用，并且不增加患者的28天死亡率和多重耐药菌感染。.
Keywords: De-Escalation; Propensity Score Matching; Trauma; Ventilator-Associated Pneumonia.