ICU · Antimicrobial Stewardship

Acute severe community-acquired pneumonia: antimicrobial de-escalation and stewardship

Also known as Antibiotic stewardship in CAP · Procalcitonin-guided therapy · De-escalation in pneumonia

Antimicrobial de-escalation is narrowing or stopping antibiotics based on culture results and clinical response. For severe CAP: start broad (a beta-lactam plus a macrolide, or a respiratory fluoroquinolone), then narrow at 48-72h based on: (1) culture results (sputum, blood, urinary antigens), (2) clinical response (improving fever, WBC, oxygenation, inflammatory markers), (3) procalcitonin trend. Procalcitonin-guided algorithm (Christ-Crain 2006 bands): antibiotics strongly discouraged under 0.1 ng/mL, discouraged under 0.25 ng/mL, encouraged over 0.25 ng/mL, strongly encouraged over 0.5 ng/mL; stop with clinical improvement. Duration: randomised trials support 3-day and 5-day minimum courses in clinically stable CAP (el Moussaoui 2006; Uranga 2016). Stewardship principles: right drug, right dose, right duration, right route. Avoid: unnecessary broadening, prolonged courses, duplicate coverage.