A Prospective Observational Study of Antimicrobial Stewardship and De-escalation in a Tertiary Intensive Care Unit

Research Article

Abstract

Optimizing antimicrobial stewardship in intensive care settings remains a primary clinical imperative to mitigate the escalation of multi-drug-resistant pathogens and improve patient survival rates. This prospective observational investigation, conducted over a continuous four-month duration in a tertiary care multi-disciplinary critical care unit, evaluates the clinical impact of active stewardship interventions, de-escalation patterns, and pharmacological dose optimization among one hundred critically ill adults. Over the observation period, empirical regimens remained unmodified in 62% of cases, whereas active stewardship modifications were implemented in 38% of patients, consisting of treatment withdrawal (19%), therapeutic de-escalation (11%), and pharmacokinetic dose adjustments (8%). Favorable clinical endpoints of discharge and clinical recovery were documented in 77% of the study population, while adverse outcomes, including death and leaving against medical advice, occurred in 23%. Culture-guided interventions exhibited a statistically significant association with clinical recovery (p = 0.041). Therapeutic de-escalation was significantly associated with reduced hospital mortality, as no deaths occurred among patients who underwent de-escalation (p = 0.048). Multivariate logistic regression identified key independent clinical predictors of adverse outcomes, including multidrug-resistant infections (OR: 3.12, 95% CI: 1.22–7.96, p = 0.017), cumulative exposure to five or more distinct antimicrobial agents (OR: 2.76, 95% CI: 1.08–7.05, p = 0.034), and prolonged intensive care stay exceeding eight days (OR: 2.48, 95% CI: 1.01–6.08, p = 0.047). Implementing structured, microbiology-driven stewardship provides an essential mechanism to minimize poly-antibiotic exposure and improve patient survival.