Does de-escalation of anti-MRSA therapy for culture-negative pneumonia affect patient outcomes?

Nosocomial pneumonia is a common hospital-acquired infection and has a high mortality rate in the critically ill.  Because drug-resistant bacteria like Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus (MRSA) are commonly responsible for these infections, guidelines recommend broad-spectrum empirical therapy that includes anti-MRSA coverage.  Treatment is ideally de-escalated and refined based on culture results.  However, culture negative infections leave a conundrum for clinicians who want to protect their patients but also minimize morbidity and inappropriate antimicrobial use.

Cowley et al. recently published a retrospective study in Chest evaluating the safety of anti-MRSA de-escalation by measuring 28-day mortality, hospital mortality, intensive care unit (ICU) and hospital length of stay (LOS), incidence of treatment failure, and incidence of acute kidney injury (AKI) in patients who were de-escalated compared to those who were not after negative culture result.  De-escalation was defined as transition to a narrower spectrum antibiotic (without MRSA coverage) within 4 days of culture. Of the 279 patients identified with culture-negative nosocomial pneumonia, 79% received vancomycin for MRSA coverage and 92% had some pseudomonal coverage in their empiric treatment.  Ninety-two met the de-escalation criteria.

The de-escalation group had a significantly higher incidence of chronic kidney disease at baseline, but the groups were otherwise well matched. There was no significant difference in 28-day mortality or treatment failure between the groups.  The de-escalation group had a shorter time to transfer out of the ICU and discharge, and they also experienced less AKI.

As Dr. Cawcutt wrote in her review, “De-escalation in culture-negative pneumonia may result in lower AKI and ICU and hospital LOS. There is clear potential benefit for patients and overall health care systems in advocating for earlier de-escalation, regardless of whether or not nares swabs were completed.”

This post is based on Dr. Cawcutt’s review in IDSA Journal Club, available here.  You can read the original article here.


Leave a comment

Your email address will not be published. Required fields are marked *

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

This site uses Akismet to reduce spam. Learn how your comment data is processed.