A Comparative Study between Escalation and De-escalation of Antibiotics in a Tertiary Care Hospital: A Prospective Observational Study

Antibiotic de-escalation is a key component of antimicrobial stewardship that aims to optimize antimicrobial therapy while reducing the emergence of antimicrobial resistance, treatment-related adverse events, and healthcare costs. However, evidence regarding its implementation in emergency care settings in India remains limited. This study evaluated the clinical characteristics and antibiotic utilization patterns among patients managed with antibiotic de-escalation versus escalation in a tertiary care hospital.

This prospective observational study was conducted over 18 months in the Emergency Department of Indira Gandhi Institute of Medical Sciences, Patna, India. A total of 200 adult patients receiving empirical antibiotic therapy were enrolled. Patients were classified into de-escalation (n = 140) or escalation (n = 60) groups based on clinical response and predefined criteria assessed within 48 h of admission. Demographic characteristics, sequential organ failure assessment (SOFA) score, acute physiology and chronic health evaluation II (APACHE II) score, laboratory parameters, and antibiotic prescribing patterns were analyzed. Continuous variables were compared using Student's t-test or Mann-Whitney U-test, and categorical variables using the Chi-square or Fisher's exact test. P < 0.05 was considered statistically significant.

Of the 200 enrolled patients, 70.0% underwent antibiotic de-escalation and 30.0% required escalation. At admission, significant differences were observed between the groups in total leukocyte count (TLC) (P < 0.001), liver function test values (P = 0.006), blood urea nitrogen (BUN) (P < 0.001), and serum creatinine (CREAT) (P = 0.002), whereas SOFA and APACHE II scores were comparable. After 48 h, significant differences were observed in SOFA score (P = 0.004), TLC (P < 0.001), BUN (P < 0.001), and serum CREAT (P < 0.001). Carbapenems and β-lactam/β-lactamase inhibitor combinations were the most frequently prescribed empirical antibiotics. Antibiotic utilization patterns differed significantly between the two groups, with patients in the de-escalation group more frequently receiving combination antibiotic therapy (P < 0.001). Clinical and laboratory parameters improved significantly following de-escalation during the first 48 h.

Antibiotic de-escalation was feasible in most patients admitted to the emergency department and was associated with favorable early clinical and laboratory outcomes. These findings support the incorporation of de-escalation strategies into antimicrobial stewardship programs to promote rational antibiotic use. Larger multicenter studies are warranted to evaluate the impact of antibiotic de-escalation on mortality, antimicrobial resistance, and long-term clinical outcomes.