De-escalation therapy is a strategy currently used for the management of nosocomial pneumonia. Mi Kyong Joung, of the Division of Infectious Diseases at Sungkyunkwan University School of Medicine in Seoul Korea, and colleagues evaluated clinical outcomes and risk factors related to de-escalation therapy in patients with intensive care unit (ICU)-acquired pneumonia.
They conducted a retrospective observational cohort study of ICU patients that developed pneumonia more than 48 hours after admission to the ICU at Samsung Medical Center from September 2004 to December 2007.
The 137 patients comprised 44 who received de-escalation therapy (32.1 percent) and 93 in the non-de-escalation group. The de-escalation group showed a lower pneumonia-related mortality rate by day 14 (2.3 percent vs. 10.8 percent, respectively; P=0.08) and day 30 (2.3 percent vs. 14 percent, respectively; P=0.03) after the diagnosis of pneumonia, compared to the non-de-escalation group. The variables independently associated with ICU-acquired pneumonia related mortality included the Acute Physiology and Chronic Health Evaluation (APACHE II) score and the modified clinical pulmonary infection score (CPIS) after five days with pneumonia. The non-de-escalation group had a significantly higher APACHE II score and the modified CPIS after five days with ICU-acquired pneumonia compared to the de-escalation group. Among all patients, 20.4 percent (28/137) had negative cultures for pathogens and 42.9 percent (12/28) received de-escalation therapy. The latter 12 patients received de-escalation therapy and survived 30 days after the diagnosis of pneumonia.
The researchers concluded that patients in the de-escalation group showed a significantly lower mortality rate compared to patients in the non-de-escalation group. De-escalation therapy can be safely provided to patients with ICU-acquired pneumonia if they are clinically stable by day five, even in those whose respiratory specimen cultures yield no specific pathogens. The research was published in Critical Care.
Reference: Joung MK, Lee J, Moon S, et al. Impact of de-escalation therapy on clinical outcomes for intensive care unit-acquired pneumonia. Critical Care 2011, 15:R79doi:10.1186/cc10072.