Antibiotic De-Escalation in Emergency General Surgery

Background. Antibiotic treatment in emergency general surgery (EGS) is a major challenge for surgeons, and a multidisciplinary approach is necessary in order to improve outcomes. Intra-abdominal infections are at high risk of increased morbidity and mortality, and prolonged hospitalization. An increase in multi-drug resistance bacterial infections and a tendency to an antibiotic overuse has been described in surgical settings. In this clinical scenario, antibiotic de-escalation (ADE) is emerging as a strategy to improve the management of antibiotic therapy. The objective of this article is to summarize the available evidence, current strategies and unsolved problems for the optimization of ADE in EGS. Methods. A literature search was performed on PubMed and Cochrane using "de-escalation", "antibiotic therapy" and "antibiotic treatment" as research terms. Results. There is no universally accepted definition for ADE. Current evidence shows that ADE is a feasible strategy in the EGS setting, with the ability to optimize antibiotic use, to reduce hospitalization and health care costs, without compromising clinical outcome. Many studies focus on Intensive Care Unit patients, and a call for further studies is required in the EGS community. Current guidelines already recommend ADE when surgery for uncomplicated appendicitis and cholecystitis reaches a complete source control. Conclusions. ADE in an effective and feasible strategy in EGS patients, in order to optimize antibiotic management without compromising clinical outcomes. A collaborative effort between surgeons, intensivists and infectious disease specialists is mandatory. There is a strong need for further studies selectively focusing in the EGS ward setting.