• Alexis Tabah, Menino Osbert Cotta, Jose Garnacho-Montero, Jeroen Schouten, Jason A Roberts, Jeffrey Lipman, Mark Tacey, Jean-François Timsit, Marc Leone, Jean Ralph Zahar, and Jan J De Waele.
• Intensive Care Unit, Royal Brisbane and Women's Hospital.
• Clin. Infect. Dis. 2016 Apr 15; 62 (8): 1009-1017.

AbstractAntimicrobial de-escalation (ADE) is a strategy to reduce the spectrum of antimicrobials and aims to prevent the emergence of bacterial resistance. We present a systematic review describing the definitions, determinants and outcomes associated with ADE. We included 2 randomized controlled trials and 12 cohort studies. There was considerable variability in the definition of ADE. It was more frequently performed in patients with broad-spectrum and/or appropriate antimicrobial therapy (P= .05 to .002), when more agents were used (P= .002), and in the absence of multidrug-resistant pathogens (P< .05). Where investigated, lower or improving severity scores were consistently associated with ADE (P= .04 to <.001). The pooled effect of ADE on mortality is protective (relative risk, 0.68; 95% confidence interval, .52-.88). Because the determinants of ADE are markers of clinical improvement and/or of lower risk of treatment failure this effect on mortality cannot be retained as evidence. None of the studies were designed to investigate the effect of ADE on antimicrobial resistance. © The Author 2015. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail journals.permissions@oup.com.

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