Impact of de-escalation therapy on clinical outcomes for intensive care unit-acquired pneumonia
1 Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Ilwon-dong, Gangnam-gu, Seoul 135-710, Republic of Korea
2 Division of Infectious Diseases, Konyang University Hospital, 685 Gasuwon-dong, Seo-gu, Daejeon 302-718, Republic of Korea
3 Division of Infectious Diseases, Kyunghee University Hospital, Hoegi-dong, Dongdaemun-gu, Seoul 130-702, Republic of Korea
4 Division of Infectious Diseases, Konkuk University Hospital, 4-12 Hwawang-dong, Gangjin-gu, Seoul 143-701, Republic of Korea
5 Division of Infectious Diseases, Chungnam National University Hospital, 33 Munhwa-ro, Jung-gu, Daejeon 301-721, Republic of Korea
6 Divisions of Pulmonary and Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Ilwon-dong, Gangnam-gu, Seoul 135-710, Republic of Korea
7 Asian-Pacific Research Foundation for Infectious Diseases, 50 Ilwon-dong, Gangnam-gu, Seoul 135-710, Republic of Korea
Critical Care 2011, 15:R79 doi:10.1186/cc10072Published: 2 March 2011
De-escalation therapy is a strategy currently used for the management of nosocomial pneumonia. In this study, we evaluated clinical outcomes and risk factors related to de-escalation therapy in patients with intensive care unit (ICU)-acquired pneumonia.
This was a retrospective observational cohort study of ICU patients who 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 (32.1%) who received de-escalation therapy and 93 in the non-de-escalation group. The de-escalation group showed a lower pneumonia-related mortality rate than the non-de-escalation group by day 14 (2.3% vs. 10.8%, respectively; P = 0.08) and by day 30 (2.3% vs. 14%, respectively; P = 0.03) after the diagnosis of pneumonia. The variables independently associated with ICU-acquired pneumonia-related mortality included the Acute Physiology and Chronic Health Evaluation II (APACHE II) score and the modified Clinical Pulmonary Infection Score (CPIS) after 5 days with pneumonia. The non-de-escalation group had significantly higher APACHE II score and modified CPIS after 5 days with ICU-acquired pneumonia compared to the de-escalation group. Among all patients, 20.4% (28 of 137) had negative cultures for pathogens, and 42.9% (12 of 28) received de-escalation therapy. The latter 12 patients received de-escalation therapy and survived 30 days after the diagnosis of pneumonia.
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 5, even in those whose respiratory specimen cultures yield no specific pathogens.