Study type Setting Patients Deescalation rate Association with outcomes Factors associated with no deescalation Rello et al., 2004 [2 ] Prospective, observational Medical-surgical ICU with VAP 115 31.4% Not reported Nonfermenting Gram-negative bacillus (2.7% versus 49.3%), late-onset pneumonia (12.5% versus 40.7%), Eachempati 3 ] Observational Surgical ICU with VAP 138 55% No difference in recurrent pneumonia rate or mortality, 34% versus 42% Not reported De Waele et al., 2010 [4 ] Retrospective Surgical ICU 113 42% No difference in mortality rate (7% versus 21%, Negative cultures, colonization with multiresistant Gram-negative organisms Hibbard et al., 2010 [5 ] Retrospective Surgical ICU, VAP 811 antibiotic days 78%–59% No change in resistance rates Not reported Morel et al., 2010 [6 ] Retrospective Mixed ICU 116 45% Recurrent infection (19% versus 5%, Inadequate empiric antibiotic and initial therapy not containing aminoglycoside Gonzalez et al., 2013 [7 ] Retrospective Medical ICU 229 51% No differences in mortality, length of stay, antibiotic duration, mechanical ventilation, ICU-acquired infection, or drug-resistant bacteria Inadequacy of initial antibiotic therapy (OR = 0.1, 0.0 to 0.1, Duchêne et al., 2013 [8 ] Retrospective Urosepsis 80 46% Not reported Shock, renal abscess, obstructive uropathy, bacterial resistance Garnacho-Montero et al., 2014 [9 ] Prospective, observational Medical 712 34.9% Deescalation protective for mortality (OR 0.54; 95% CI 0.33-0.89) Not reported Carugati et al., 2015 [10 ] Secondary analysis of CAP database Medical with CAP 261 63.2% No association with mortality More severe presentation Lee et al., 2015 [11 ] Retrospective Community-onset monomicrobial Enterobacteriaceae (CoME) bacteremia 189 45.5% Deescalation strategy was protective for mortality (OR 0.37, Not reported Madaras-Kelly et al., 2016 [12 ] Retrospective HCAP in VA system 9319 28.3% Not reported Deescalation associated with initial broad-spectrum therapy (OR 1.5, 95% CI 1.4–1.5), collection of respiratory tract cultures (OR 1.1, 95% CI 1.0–1.2), care in higher complexity facilities (OR 1.3, 95% CI 1.1–1.6) Falguera et al., 2010 [13 ] RCT Community-acquired pneumonia 177, deescalation by urinary antigen results — Higher cost ( Kim et al., 2012 [14 ] RCT Medical ICU, hospital-acquired pneumonia 109 — No differences in ICU stay or mortality rates, higher risk of MRSA with deescalation; HR 3.84; 95% CI 1.06–13.91 Leone et al., 2014 [15 ] Multicenter, RCT Severe sepsis 60 — Deescalation resulted in prolonged duration of ICU stay; mean difference 3.4 (95% CI −1.7–8.5); no effect on mortality Not reported
