I am so glad that this post essentially reaffirms my practice. Especially the fact that consultants e.g ID at my specific hospital are notorious for extended antibiotic use. For example, a patient with pulmonary edema due to severe mitral valve regurgitation requiring emergent transfer to the intensive care unit remains on prolonged antibiotic therapy due to a chest x-ray that has been read as bilateral pulmonary infiltrates. as intensivist we are recording the movie, consultants are only taking snapshots.
As a nocturnist, I’m the one doing the starting but not the stopping of antibiotics. I work in a community academic center. One of the arguments I make frequently to residents is “what is broad spectrum?” I’m an advocate for narrowest targeted treatment.
— All antibiotics get end dates (on the shorter side) when ordered based on infection site.
— MRSA coverage only if risks or after a positive screen if no risks.
— If this is a community-acquired infection, no need for pseudomonas or ESBL coverage unless patient history of the same.
— If diagnosis of infection is unclear, I’ll send a procalcitonin, although it won’t come back for 3 days, to help my colleagues feel more comfortable de-escalating.
All of this goes out the window for a patient I am “throwing the kitchen sink at” because they are incredibly unstable. I find my daytime rounding colleagues rarely escalate further, and if they do it is usually when the patient is not improving quickly, which is reasonable.
Completely agree with the 5 point framework. Few added questions I consider when early de-escalation (more gestalt than purely evidence based)-
- patient specific risk factors - immunosuppressed, comorbidities like chonic lung disease/chronic respiratory failure, cirrhotic, poor functional status, NH pt. Similar to what comprises risk scores such as DRIP for example, while understanding guidelines don't recommend using scores rigidly.
- undrained source?
- maybe controversial takes- --with shift based ICU staffing, I hesitate to deescalate on first day on service when possible, preferring to monitor the trend myself and reassess on day 2. Not always, but when there's enough gray in the case.
--if patient was especially unstable (multiple pressors), prefer monitor in ICU 1 day before downgrade. Often this is not possible due to bed needs and staffing.
I basically follow that process with a few caveats:
1) patient started on abx in ER for unnecessary reasons (ie aspiration, pancreatitis, +UA no symptoms, CHF, diarrhea) and no real sign of infection, patient not sick… stop them on day 1 morning rounds. Sometimes procal useful here to “back up” this decision. It’s almost always super low like 0.1. This probably applies to 30% or more of our admissions.
2) surgical patients getting better, cultures negative… 2-3 days
3) suspected respiratory infection but culture negative and someone checked a procal at some point, I’ll definitely stop if repeat procal 80% drop or <0.5
4) anyone on over a week of broad spectrum abx I stop and monitor unless ID wants it or we are treating something specific. But a lot of people (esp surgical) are on like day 11 of meropenem micafungin for no clear reason and no stop date)
5) anyone undifferentiated or worsening stays on broad spectrum abx and often escalate even with negative cultures or source
We use MRSA nares a lot to de escalate less sick patients. Result back same day. Same with procal, we get it back in a few hours.
I am so glad that this post essentially reaffirms my practice. Especially the fact that consultants e.g ID at my specific hospital are notorious for extended antibiotic use. For example, a patient with pulmonary edema due to severe mitral valve regurgitation requiring emergent transfer to the intensive care unit remains on prolonged antibiotic therapy due to a chest x-ray that has been read as bilateral pulmonary infiltrates. as intensivist we are recording the movie, consultants are only taking snapshots.
As a nocturnist, I’m the one doing the starting but not the stopping of antibiotics. I work in a community academic center. One of the arguments I make frequently to residents is “what is broad spectrum?” I’m an advocate for narrowest targeted treatment.
— All antibiotics get end dates (on the shorter side) when ordered based on infection site.
— MRSA coverage only if risks or after a positive screen if no risks.
— If this is a community-acquired infection, no need for pseudomonas or ESBL coverage unless patient history of the same.
— If diagnosis of infection is unclear, I’ll send a procalcitonin, although it won’t come back for 3 days, to help my colleagues feel more comfortable de-escalating.
All of this goes out the window for a patient I am “throwing the kitchen sink at” because they are incredibly unstable. I find my daytime rounding colleagues rarely escalate further, and if they do it is usually when the patient is not improving quickly, which is reasonable.
Completely agree with the 5 point framework. Few added questions I consider when early de-escalation (more gestalt than purely evidence based)-
- patient specific risk factors - immunosuppressed, comorbidities like chonic lung disease/chronic respiratory failure, cirrhotic, poor functional status, NH pt. Similar to what comprises risk scores such as DRIP for example, while understanding guidelines don't recommend using scores rigidly.
- undrained source?
- maybe controversial takes- --with shift based ICU staffing, I hesitate to deescalate on first day on service when possible, preferring to monitor the trend myself and reassess on day 2. Not always, but when there's enough gray in the case.
--if patient was especially unstable (multiple pressors), prefer monitor in ICU 1 day before downgrade. Often this is not possible due to bed needs and staffing.
I basically follow that process with a few caveats:
1) patient started on abx in ER for unnecessary reasons (ie aspiration, pancreatitis, +UA no symptoms, CHF, diarrhea) and no real sign of infection, patient not sick… stop them on day 1 morning rounds. Sometimes procal useful here to “back up” this decision. It’s almost always super low like 0.1. This probably applies to 30% or more of our admissions.
2) surgical patients getting better, cultures negative… 2-3 days
3) suspected respiratory infection but culture negative and someone checked a procal at some point, I’ll definitely stop if repeat procal 80% drop or <0.5
4) anyone on over a week of broad spectrum abx I stop and monitor unless ID wants it or we are treating something specific. But a lot of people (esp surgical) are on like day 11 of meropenem micafungin for no clear reason and no stop date)
5) anyone undifferentiated or worsening stays on broad spectrum abx and often escalate even with negative cultures or source
We use MRSA nares a lot to de escalate less sick patients. Result back same day. Same with procal, we get it back in a few hours.