• Michael S Niederman.
• Department of Medicine, Winthrop-University Hospital, Mineola, New York, USA. mniederman@winthrop.org
• Curr Opin Crit Care. 2006 Oct 1;12(5):452-7.

Purpose Of ReviewTo describe the use of a 'de-escalation' strategy to deliver appropriate empiric therapy for ventilator-associated pneumonia, without the overuse of antibiotics.Recent FindingsInitial empiric therapy can be appropriate in 80-90% of ventilator-associated pneumonia patients, if it is selected on the basis of local microbiologic data or individual patient surveillance cultures. Following initial empiric therapy, de-escalation means using microbiologic and clinical data to change from an initial broad-spectrum, multidrug empiric therapy regimen to a therapy with fewer antibiotics and agents of narrower spectrum. In spite of early success with this approach there is an opportunity to de-escalate more often, particularly in patients with negative pretherapy cultures, and in those whose cultures show multidrug-resistant organisms, including Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus. In addition, it is possible to reduce the total duration of therapy, particularly when the initial therapy is accurate. When de-escalation has been employed, it has led to less antibiotic usage, shorter durations of therapy, fewer episodes of secondary pneumonia and reduced mortality, without increasing the frequency of antibiotic resistance.SummaryDe-escalation is a promising strategy for optimizing the responsible use of antibiotics while allowing the delivery of prompt and appropriate empiric therapy of ventilator-associated pneumonia.

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