De-escalation in lower respiratory tract infections

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Abstract
Purpose of review The present article reviews recent data on the de-escalation of empirical antibiotic treatment on pneumonia, with special attention to newer strategies aimed at increasing adequacy and minimizing resistance emergence risks in ventilator-associated pneumonia. Recent findings A de-escalation strategy is feasible in a large proportion of patients with pneumonia, and at least two reports have associated de-escalation with a significantly better survival. Combined with other strategies, such as using biomarkers (e.g. C-reactive protein or procalcitonin), antibiotic heterogeneity, adherence to local microbiological flora, objective clinical criteria of non-response and of clinical ventilator-associated pneumonia resolution, they contribute to rationalizing and individualizing antimicrobial therapy. Summary A patient-based approach with prompt adequate empirical therapy, using broad-spectrum antibiotics based on reliable local microbiological data with streamlining as soon as microbiological data become available, allow outcomes to be improved and the emergence of resistance to be minimized.