Is de-escalation of antimicrobials effective? A systematic review and meta-analysis

•De-escalation therapy is commonly used in many clinical settings to balance clinical efficacy and the prevention of overuse of broad-spectrum antimicrobials.•There is a paucity of evidence to support de-escalation, and a recent Cochrane review was not able to include any randomized controlled trials in the analysis.•A systematic review and meta-analysis was conducted for various types of infection, allowing observational studies to be included in the analysis.•De-escalation appeared safe and not to impair clinical effectiveness in most infections, but the quality of most of the studies included was not very high.

SummaryBackgroundDe-escalation therapy is a strategy used widely to treat infections while avoiding the use of broad-spectrum antimicrobials. However, there is a paucity of clinical evidence to demonstrate the effectiveness and safety of de-escalation therapy compared to conventional therapy.MethodsA systematic review and meta-analysis was conducted on de-escalation therapy for a variety of infections. A search of the MEDLINE (via PubMed), EMBASE, and Cochrane Library databases up to July 2015 for relevant studies was performed. The primary outcome was relevant mortality, such as 30-day mortality and in-hospital mortality. A meta-analysis was to be conducted for the pooled odds ratio using the random-effects model when possible. Both randomized controlled trials and observational studies were included in the analysis.ResultsA total of 23 studies were included in the analysis. There was no difference in mortality for most infections, and some studies favored de-escalation over non-de-escalation for better survival. The quality of most studies included was not high.ConclusionsThis review and analysis suggests that de-escalation therapy is safe and effective for most infections, although higher quality studies are needed in the future.