Antimicrobial stewardship programmes focused on de-escalation: a narrative review of efficacy and risks

Background and Objective: Multi-drug resistance is an increasing problem and is associated with increased morbidity and mortality. High levels of antimicrobial consumption and broad-spectrum antimicrobial use are associated with antimicrobial resistance (AMR). Studies have shown substantial antimicrobial use across intensive care units (ICUs) worldwide. International guidelines advise antibiotic de-escalation (ADE) as part of an antimicrobial stewardship programme (ASP). ADE is a strategy to decrease the spectrum of the empirical antimicrobial therapy, with the aim to reduce the ecological impact on the patient’s microbiome and reduce the emergence of AMR. Our aim was to provide an insight into the latest developments on ADE in the intensive care setting. Methods: PubMed was searched using the terms ‘antibiotic de-escalation’ and ‘antimicrobial stewardship’ up to and including November 2021. Key Content and Findings: Evidence to date is limited, ADE appears to be a safe intervention. The evidence is inconclusive regarding resistance development. Concerns regarding increased duration and superinfections with an ADE approach are unproven with studies finding mixed results. ADE should not be used as a sole quality indicator as this could encourage empiric broad-spectrum antimicrobial overuse. Conclusions: ADE appears safe. Evidence is inconclusive regarding resistance development but data to date is limited. ADE should be used alongside other antimicrobial stewardship (AMS) measures. These include appropriate empirical therapy, guided by local guidelines considering local epidemiology and host factors, optimal dosing, regular review of antimicrobial therapy with clinical progress and microbiology results, with de-escalation as soon as feasible and early cessation where appropriate, and infection control measures.