Background Little is known about the frequency, hospital-level variation, predictors, and outcomes of antibiotic de-escalation in suspected sepsis. Methods We retrospectively analyzed adults admitted to 236 US hospitals from 2017–2021 with suspected sepsis (defined by blood culture draw, lactate measurement, and intravenous antibiotic administration) who were initially treated with ≥2 days of anti–methicillin-resistant Staphylococcus aureus (MRSA) and anti-pseudomonal antibiotics but had no resistant organisms that required these agents identified through hospital day 4. De-escalation was defined as stopping anti-MRSA and anti-pseudomonal antibiotics or switching to narrower antibiotics by day 4. We created a propensity score for de-escalation using 82 hospital and clinical variables; matched de-escalated to non–de-escalated patients; and assessed associations between de-escalation and outcomes. Results Among 124 577 patients, antibiotics were de-escalated in 36 806 (29.5%): narrowing in 27 177 (21.8%), cessation in 9629 (7.7%). De-escalation rates varied between hospitals (median, 29.4%; interquartile range, 21.3%–38.0%). Predictors of de-escalation included less severe disease on day 3–4, positive cultures for nonresistant organisms, and negative/absent MRSA nasal swabs. De-escalation was more common in medium, large, and teaching hospitals in the Northeast and Midwest. De-escalation was associated with lower adjusted risks for acute kidney injury (AKI) (odds ratio [OR], 0.80; 95% confidence interval [CI], .76–.84), intensive-care unit (ICU) admission after day 4 (OR, 0.59; 95% CI, .52–.66), and in-hospital mortality (OR, 0.92; 95% CI, .86–.996). Conclusions Antibiotic de-escalation in suspected sepsis is infrequent, variable across hospitals, linked with clinical and microbiologic factors, and associated with lower risk for AKI, ICU admission, and in-hospital mortality.

中文翻译：

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美国医院疑似脓毒症患者抗生素降级的流行病学和结局


背景 对疑似脓毒症抗生素降级的频率、医院水平差异、预测因子和结果知之甚少。方法 我们回顾性分析了 2017 年至 2021 年美国 236 家医院收治的疑似脓毒症（通过血培养抽取、乳酸测定和静脉注射抗生素给药定义）的成年人，这些患者最初接受了 ≥2 天的抗甲氧西林耐药金黄色葡萄球菌 （MRSA） 和抗假单胞菌抗生素治疗，但在住院第 4 天没有需要识别这些药物的耐药微生物。降级定义为在第 4 天停止抗 MRSA 和抗假单胞菌抗生素或在第 4 天改用更窄的抗生素。我们使用 82 个医院和临床变量创建了降级倾向评分;匹配降级至未降级的患者;并评估降级与结果之间的关联。结果 124 577 例患者中，36 806 例 （29.5%） 抗生素降级： 27 177 例 （21.8%），9629 例 （7.7%） 停止使用。降级率因医院而异（中位数，29.4%;四分位距，21.3%-38.0%）。降级的预测因素包括第 3-4 天病情较轻、非耐药微生物培养阳性以及 MRSA 鼻拭子阴性/不存在。降级在东北部和中西部的中型、大型和教学医院更为常见。降级与急性肾损伤 （AKI） 的调整后风险较低相关 （比值比 [OR]，0.80;95% 置信区间 [CI]，.76–.84）、第 4 天后重症监护病房 （ICU） 收治 （OR，0.59;95% CI，.52–.66） 和院内死亡率 （OR，0.92;95% CI，.86–.996）。 结论 疑似脓毒症患者的抗生素降级并不常见，因医院而异，与临床和微生物学因素有关，并且与 AKI 、 ICU 收治和院内死亡率风险较低相关。