Epidemiology and Outcomes of Antibiotic De-escalation in Patients With Suspected Sepsis in US Hospitals

Abstract

Abstract Background Little is known about the frequency, hospital-level variation, predictors, and outcomes of antibiotic de-escalation in suspected sepsis. Methods We retrospectively analyzed adults admitted to 236 US hospitals from 2017–2021 with suspected sepsis (defined by blood culture draw, lactate measurement, and intravenous antibiotic administration) who were initially treated with ≥2 days of anti–methicillin-resistant Staphylococcus aureus (MRSA) and anti-pseudomonal antibiotics but had no resistant organisms that required these agents identified through hospital day 4. De-escalation was defined as stopping anti-MRSA and anti-pseudomonal antibiotics or switching to narrower antibiotics by day 4. We created a propensity score for de-escalation using 82 hospital and clinical variables; matched de-escalated to non–de-escalated patients; and assessed associations between de-escalation and outcomes. Results Among 124 577 patients, antibiotics were de-escalated in 36 806 (29.5%): narrowing in 27 177 (21.8%), cessation in 9629 (7.7%). De-escalation rates varied between hospitals (median, 29.4%; interquartile range, 21.3%–38.0%). Predictors of de-escalation included less severe disease on day 3–4, positive cultures for nonresistant organisms, and negative/absent MRSA nasal swabs. De-escalation was more common in medium, large, and teaching hospitals in the Northeast and Midwest. De-escalation was associated with lower adjusted risks for acute kidney injury (AKI) (odds ratio [OR], 0.80; 95% confidence interval [CI], .76–.84), intensive-care unit (ICU) admission after day 4 (OR, 0.59; 95% CI, .52–.66), and in-hospital mortality (OR, 0.92; 95% CI, .86–.996). Conclusions Antibiotic de-escalation in suspected sepsis is infrequent, variable across hospitals, linked with clinical and microbiologic factors, and associated with lower risk for AKI, ICU admission, and in-hospital mortality.