Examples illustrating decisions related to the de-escalation process for patients with positive and negative cultures.
| Decision | Example |
|---|---|
| Incorrectly de-escalated (de-escalation from broad to narrow spectrum despite negative culture result) | An 88-year-old female was admitted to JUH. The patient received intravenous levofloxacin before the results of the blood culture were available. Within 48 h of admission, the culture results showed no bacterial growth. Subsequently, the patient’s treatment was de-escalated to ceftriaxone sodium injection 1 g on the following day, coinciding with the availability of the culture results. |
| Incorrectly de-escalated (transition from multiple antibiotics to a single antibiotic despite a negative culture result) | An 81-year-old male was admitted to JUH. The patient received intravenous levofloxacin and piperacillin/tazobactam injections before the results of the blood culture were available. After more than 72 h of admission, the culture result showed no bacterial growth. Levofloxacin was discontinued, and the patient continued with piperacillin/tazobactam on the same day that the culture results became available. |
| Failed de-escalation (continued all antibiotics despite negative culture results) | A 100-year-old male was admitted to JUH. The patient received intravenous levofloxacin, intravenous vancomycin, and intravenous imipenem before the culture results were available. After more than 72 h of admission, both blood and sputum cultures showed no bacterial growth. The patient’s treatment was maintained with intravenous levofloxacin, intravenous vancomycin, and intravenous imipenem after the culture results became available. |
| Failed de-escalation (increased number of antibiotics despite negative culture result) | A 63-year-old female was admitted to JUH. The patient received intravenous levofloxacin before the results of the blood culture were available. Within 72 h of admission, the blood culture showed no bacterial growth. The patient’s treatment regimen was adjusted, and she began receiving intravenous piperacillin/tazobactam injection in addition to levofloxacin on the same day as the culture results became available. |
| Successfully de-escalated (discontinuation of antibiotic for negative culture result) | A 71-year-old male was admitted to JUH. The patient received intravenous levofloxacin, intravenous piperacillin/tazobactam, and oral amoxicillin/clavulanic acid tablets before the results of the blood culture were available. After more than 72 h of admission, the blood culture showed no bacterial growth. Consequently, the patient’s treatment was de-escalated, and all antibiotics were discontinued on the same day as the culture results became available. |
| Failed de-escalation (continued all antibiotics despite colonization, which suggests negative culture results) | A 60-year-old male was admitted to JUH with suspected community-acquired pneumonia and was started empirically on intravenous levofloxacin and piperacillin/tazobactam. Within 48 h, culture results showed Staphylococcus hominis isolated from a non-sterile respiratory sample. Despite this result, which likely represented colonization rather than true infection, the broad-spectrum antibiotics were continued rather than de-escalated or discontinued. |
| Failed de-escalation (increased the number of antibiotics used despite suitability for narrower-spectrum antibiotics) | A 76-year-old female was admitted to JUH. The patient received intravenous levofloxacin, vancomycin, and meropenem before the availability of culture results. More than 72 h after admission, a culture result was received, revealing the presence of Acinetobacter baumannii. Despite suitability of narrower antibiotics, gentamycin was initiated in addition to the ongoing antibiotics levofloxacin, vancomycin, and meropenem. |
| Incorrectly de-escalated (stopping antibiotics instead of converting to a narrow spectrum in culture result) | A 55-year-old female was admitted to JUH. The patient received intravenous levofloxacin in addition to imipenem/cilastatin before the results of the culture were available. After more than 72 h of admission, the culture result showed the presence of Staphylococcus aureus. Subsequently, the patient’s treatment was discontinued, and all antibiotics were stopped, leaving the patient untreated. |
| Successfully de-escalated (transitioned to narrower spectrum antibiotics for positive culture results) | An 88-year-old male was admitted to JUH. The patient received intravenous levofloxacin and imipenem/cilastatin before the culture results were available. After more than 72 h of admission, the culture results showed the presence of Escherichia coli. Subsequently, the patient’s treatment was transitioned from the broad-spectrum levofloxacin to the narrower-spectrum vancomycin in addition to imipenem/cilastatin. |
| Successfully de-escalated (transition from multiple antibiotics to a single antibiotic for positive culture results) | A 65-year-old female was admitted to JUH. The patient received intravenous levofloxacin, meropenem, gentamycin, and ceftazidime/avibactam. Within 72 h of admission, the culture result showed the presence of Klebsiella pneumoniae. Levofloxacin was discontinued, and the patient’s treatment was continued with intravenous meropenem, gentamycin, and ceftazidime/avibactam without levofloxacin. |
JUH: Jordan University Hospital.