Twenty-four percent of the recommendations were to discontinue antibiotics; 2 % to streamline antibiotics; and 11 % to shorten the course of antibiotics.
c"Other recommendations" include switching to less expensive carbapenems (9 cases), streamlining antibiotics (2 cases) and addition of antifungal agents (2 cases).
Indeed, for severely ill patients, international guidelines recommend the use of broad-spectrum antibiotics as first-line therapy to minimize the risk of inadequate initial antimicrobial treatment, and suggest streamlining initial antibiotic therapy and narrowing the spectrum whenever possible once the pathogen(s) are identified [10].
This can help identify patients at risk of pseudomonal infections and streamline their antibiotic therapy.
First, clinicians and microbiologists must be encouraged to obtain appropriate microbiological samples before starting empiric therapy to streamline the antibiotic strategy, particularly in the critically ill.
Antibiotic de-escalation, which consists of the initial institution of empiric broad-spectrum antibiotics followed by antibiotic streamlining driven by microbiological documentation, is thought to provide maximum benefit for the individual patient, while reducing the selection pressure for resistance.
In this study, initial empiric antibiotics were streamlined in 51.9% episodes with susceptible microbial isolates in patients who were given appropriate initial therapy.
Antibiotics were streamlined to a narrow spectrum in 12 patients (27.3%), whereas 7 patients (15.9%) received de-escalation therapy by decreasing the number as well as the spectrum of antibiotics.
Of the remaining patients, antibiotics were streamlined in 56 (23%) patients and remained unchanged in 14 (6%) patients based on microbiology data, in 38 (16%) patients despite microbiology data favouring de-escalation, and in 113 (46%) patients due to unknown aetiology.
Overall, antibiotics were streamlined in only nine of 39 patients (23.1%) with potentially multiresistant pathogens (for example, NFGNB and MRSA), compared with 47 of 69 patients (68.1%) among the remaining pathogens (P < 0.001).
