Treatment de-escalation in nosocomial pneumonia shortens hospital stay, lowers AKI risk
Among patients with culture-negative nosocomial pneumonia, de-escalation of antimethicillin-resistant Staphylococcus aureus (MRSA) therapy is associated with a shorter hospital stay and lower incidence of acute kidney injury (AKI), a study suggests. De-escalation does not alter 28-day mortality.
This single-centre cohort study included 279 adult patients with nosocomial pneumonia and a negative respiratory culture. Treatment dose was de-escalated in 187 patients (DE group) and maintained in 92 (control group). De-escalation was defined as discontinuation of an anti-MRSA medication within 4 days of initiation.
Compared with those in the DE group, controls received 5 more days of MRSA coverage. This difference, notwithstanding, the primary outcome of 28-day mortality was comparable (28 percent in the DE group vs 23 percent in the control group; difference, –5.5 percent; 95 percent CI, –16.1 to 6.5).
Patients who underwent treatment de-escalation had shorter hospital (15 vs 20 days; difference, 3.2 days; 0.1–6.4) and intensive care unit (10 vs 13 days; difference, 2.2 days; –0.3 to 4.9) length of stays relative to controls.
Furthermore, significantly more patients in the control vs DE group developed AKI (36 percent vs 50 percent; difference, –13.8 percent; –26.9 to –0.4).
Current guidelines recommend nosocomial pneumonia patients with risk factors for MDR pathogens to be given a triple regimen, with dual coverage of Gram-negative pathogens and MRSA. In an unrelated article, an expert commented that treatment de-escalation in nosocomial pneumonia matters, since it reduces selection pressure, organ toxic effects and costs. [Lancet Infect Dis 2011;11:155-157]