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Antibiotic de-escalation
Everyone seems to agree that antibiotic de-escalation therapy seems to make
sense.
The big question is therefore why aren’t we doing it?
Antibiotic de-escalation therapy is the practice of using more powerful antibiotics,
earlier in treatment, for a short period of time – and then switching to a less
powerful antibiotic once the infection is accurately diagnosed and under control.
One could argue that the concept of “hit hard – hit fast” is not new.
So why is this the case?
I think that part of the conundrum is the disease process itself, which frequently is
one of escalation. A patient presenting on a ward in hospital may not initially have
a “serious” infection. They may be admitted for something quite different, like a
broken limb, and have no infection at all. But within a matter of days this situation
can change and, in particular for the more elderly complicated patients with
underlying diseases/co-morbidities, the situation can deteriorate very rapidly.
“…de-escalation makes good sense and should be practiced.”
For example: It would seem unnecessary, foolish even, to commence therapy for a
mild chest infection with a very powerful antibiotic when the clinical signs and
symptoms do not warrant this. But in some patients what appears to be a mild
infection can progress to a more serious clinical situation.
Diagnostic techniques in microbiology have still not advanced to the stage where
early detection of a causative pathogen can be easily made. It remains the case that
a 48 hour period will lapse before microbiological results can be obtained. So what
happens then?
The results may reveal not one, but several bacteria, are present. This then
becomes a sort of bacterial “whodunit”? Are we witnessing a genuine
polymicrobial infection or are some of those bacteria simply colonizing and not
infecting the patient? Which one is the real culprit and how should we target
therapy to deal with it? In some cases the microbiological results reveal…nothing!