Effect of de-escalation antibiotic therapy on hospital-acquired, ventilator associated, and healthcare-associated pneumonia: A systematic review and meta-analysis

Background: The clinical impacts of de-escalation antibiotic therapy on hospital-acquired (HAP), ventilator-associated (VAP), and healthcare-associated pneumonia (HCAP) have not been fully evaluated using a systematic review and meta-analysis. Methods: We conducted a systematic review of studies examining de-escalation therapy in patients with HAP, VAP, or HCAP using PubMed, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews. A meta-analysis was conducted using a random-effects model (DerSimonian–Laird method) to measure mortality as the primary outcome and the lengths of hospital stay, intensive care unit stay, and antibiotic therapy as the secondary outcomes. Results: Among eligible eleven studies (2,621 patients), six were cohort studies, and the remaining five studies were “before-and-after” investigations implementing guideline-oriented de-escalation therapy. In all eligible studies, de-escalation had no effect on hospital mortality (odds ratio [OR], 0.85; 95% confidence interval [95%CI], 0.58–1.25). In subgroup analysis, studies that examined de-escalation vs. non-de-escalation showed a possible but statistically insignificant effect on mortality (OR, 0.61; 95%CI, 0.34–1.11), while “before-and-after” investigations tended to reveal an increased mortality risk (OR, 1.18; 95%CI, 0.73–1.91). Studies with APACHE II scores of≤20 tended to show a reduced mortality risk (OR, 0.86; 95%CI, 0.35–2.11). Conclusions: De-escalation antibiotic therapy had a possible effect on HAP/VAP/HCAP in terms of reducing mortality, especially cases of less severe disease.