Rediscussion on the clinical application of antimicrobial de-escalation / 中国小儿急救医学

Antimicrobial de-escalation is defined as the discontinuation of one or more components of combination empirical therapy, and/or the change from a broad-spectrum to a narrower spectrum antimicrobial.Antimicrobial de-escalation is one of the mostly used antibiotic management strategies in intensive care units.This review discussed current situations and possible obstacles for its implementations.

Intervention effect of descending noninvasive positive pressure ventilation on postoperative hypoxemia in patients with Stanford type A aortic dissection complicated with obesity / 中国实用护理杂志

Objective:To investigate the effect of deescalation noninvasive positive pressure ventilation in the removal of endotracheal intubation in patients with Stanford type A aortic dissection (AAD) complicated with obesity.Methods:A total of 80 obese patients with AAD from March 2018 to January 2020 in the First Affiliated Hospital of Xi′an Jiaotong University were divided into experimental group and control group with 40 cases in each group by random number table method. The control group received traditional oxygen treatment with mask, while the experimental group received de-escalation noninvasive positive pressure ventilation. The blood gas index, respiratory rate and respiratory comfort score was recorded at different times before and after intervention, make a comparison with the two groups in the incidence of hypoxemia, secondary intubation and other complications.Results:Finally, 36 cases were included in the experimental group and 38 cases in the control group. After 2, 8, 24, 48, 72 h of extubation, the oxygenation index, PaO 2, SaO 2 were higher and PaCO 2, respiratory rate were lower in the experimental group compared to the control group, the differences were statistically significant ( t values were 2.02-9.00, all P<0.05). At 72 h after extubation, the pH value of the experimental group was 7.43 ± 0.08, which was higher than 7.38 ± 0.09 of the control group, and the difference was statistically significant ( t=2.44, P<0.05). At 24, 48, 72 h after extubation, the throat pain scores and oral nasal dryness symptom and sore throat symptom scores were (3.11 ± 1.53), (2.25 ± 0.57), (0.94 ± 0.14) points and (4.33 ± 1.08), (3.33 ± 0.68), (2.81 ± 0.43) points in the experimental group, lower than in the control group (5.24 ± 1.96), (3.58 ± 0.73), (2.18 ± 0.91) points and (6.00 ± 1.92), (5.39 ± 1.13), (4.79 ± 0.54) points, the differences were statistically significant ( t values were 3.46-5.21, all P<0.05). The incidence of hypoxemia, secondary intubation and intolerance were 2.8% (1/36), 2.8% (1/36) and 0 in the experimental group, lower than in the control group 26.3% (10/38), 21.1% (8/38) and 10.5% (4/38), the differences were statistically significant ( χ2=8.09, 5.78, 4.01, all P<0.05). Conclusions:De-escalation noninvasive positive pressure ventilation for obese patients with AAD can effectively improve oxygenation, reduce the incidence of hypoxemia and secondary intubation, and alleviate respiratory symptoms.

De-escalation of Immunomodulators and Biological Agents in Inflammatory Bowel Disease / 胃肠病学

Immunomodulators and biological agents are widely used in inflammatory bowel disease (IBD), and induce remission effectively. However, these drugs are related to serious adverse events, and coupled with increasing treatment costs. Therefore, once patients with IBD are in remission, the safety and feasibility of drug de-escalation should be considered, and the risk of continuing medical therapy against the risk of disease relapse must be weighed. This review article analyzed the published literatures on de-escalation of immunomodulators and biological agents in patients with Crohn's disease and ulcerative colitis, identifying the risk factors of relapse after drug withdrawal, such as disease activity, prognostic features and previous disease course, and discussed the strategies for de-escalation and use of proactive therapeutic drug monitoring, so as to provide some guidance for clinical practice.

The application progress of fluid de-escalation therapy in abdominal infection-induced septic shock / 中华危重病急救医学

After adequate fluid resuscitation in the early stage of septic shock, excessive accumulation of fluid in the body leads to organ dysfunction, which prolongs hospitalization, mechanical ventilation time, and renal replacement therapy time, and is associated with poor prognosis. The fluid de-escalation therapy is an important fluid management strategy performed in the late stage of septic shock. It aims to clear excess fluid by restricting fluid infusion, using diuretics and renal replacement therapy to achieve a negative fluid balance. The fluid de-escalation therapy contributes to improve clinical outcome of septic shock patients and reduce the mortality. This review mainly discusses the current researches and application progress of the fluid de-escalation therapy of abdominal infection-induced septic shock through clarifying its origin, time and endpoint, method of the therapy, the relationship with the control of the source of abdominal infection and its impact on organ function and clinical outcome. Our study intends to provide guidance for the treatment of abdominal infection-induced septic shock in the late stage, and explore the novel research directions.

Safety and Efficacy Profile of CSE-1034 as a Prolonged De-escalation Therapy in Prosthetic Joint Infection: A Case Report

Background: Although rare, infection is considered to be most dreadful of the prosthetic related complications resulting in repeated surgical intervention, extended hospitalization or sometimes in loss of implant or permanent disability if not treated promptly. Poor treatment outcome associated with prosthetic joint infections (PJIs) could be partly attributed to rise in anti-microbial resistance among the causative agents. Case Presentation: This is a first reported case of ceftriaxone + sulbactam + ethylenediaminetetraacetic acid (CSE 1034) being used as an de-escalation therapy for more than 24 days with good safety and efficacy outcome in a 78 year male patient with PJI associated with hip replacement surgery, treated initially with meropenem and colistin followed by prolonged de-escalation therapy (24 days).Conclusions: In clinically complicated cases of deep infections where prolonged use of last resort antibiotics is used, CSE-1034 can be considered as a safe, efficacious and economical de-escalating antibiotic to complete the treatment course and prevent recurrence of infection, especially in PJI

Impacto clínico del desescalamiento a ertapenem en pacientes críticos con infecciones por Enterobacteriaceae / Clinical impact of ertapenem de-escalation in critically-ill patients with Enterobacteriaceae infections

Resumen Introducción: Ertapenem ha demostrado eficacia frente a Enterobacteriaceae productoras de β-lactamasas de espectro extendido, pero carece de actividad contra bacterias no fermentadoras; el desescalamiento a este antimicrobiano cuando no existe la presencia de P. aeruginosa podría reducir la presión selectiva contra esta bacteria y mejorar los resultados clínicos. Objetivo: Evaluar el impacto clínico del desescalamiento de antimicrobianos con cobertura anti-pseudomonas a ertapenem, un agente sin este espectro, en pacientes críticos con infecciones por Enterobacteriaceae. Métodos: Se realizó un estudio de cohorte prospectivo en adultos admitidos a Unidades de Cuidado Intensivo (UCI) con infecciones por Enterobacteriaceae, que habían sido desescalados de una cobertura anti-pseudomonas, a un antimicrobiano sin la misma (ertapenem). Se realizó un modelo de riesgo proporcional de Cox comparando mortalidad por cualquier causa y duración de estancia hospitalaria entre aquellos pacientes que permanecieron con cobertura anti-pseudomonas versus aquellos que fueron desescalados a ertapenem. Resultados: 105 pacientes en el grupo anti-pseudomonas fueron comparados con 148 pacientes del grupo de desescalamiento a ertapenem. El desescalamiento estuvo asociado con una menor mortalidad por cualquier causa comparado con los pacientes que permanecieron con cobertura anti-pseudomonas (hazard ratio ajustado 0,24; IC 95%: 0,12-0,46). La estancia hospitalaria en UCI fue similar en ambos grupos. Discusión: Los pacientes de UCI con infecciones por Enterobacteriaceae desescalados a terapia con ertapenem, tuvieron mejores resultados clínicos comparados con aquellos que permanecieron en terapia anti-pseudomonas, sugiriendo que el desescalamiento es una práctica segura en esta población.

Background: Ertapenem has proven to be effective for extended-spectrum beta-lactamases-producing Enterobacteriaceae but lacks activity against non-fermenters; de-escalation to this antibiotic may reduce the selection of resistance to Pseudomonas aeruginosa and improve clinical outcomes. Aim: To evaluate the clinical impact of de-escalation from broad-spectrum anti-pseudomonal agents to ertapenem, a non-pseudomonal antibiotics for Enterobacteriaceae infections in critically-ill patients. Methods: We conducted a prospective cohort study in adult patients admitted to intensive care units (ICUs) who had Enterobacteriaceae infections and were de-escalated from empiric anti-pseudomonal coverage to non-pseudomonal antibiotics. Cox proportional hazards models were performed comparing all-cause mortality and length of hospital stay between patients who remained on anti-pseudomonal coverage versus those who were de-escalated to ertapenem. Results: 105 patients in the anti-pseudomonal group were compared to 148 patients in the ertapenem de-escalation group. De-escalation was associated with lower all-cause mortality compared to patients who remained on anti-pseudomonal coverage (adjusted Hazard Ratio 0.24; 95% CI: 0.12-0.46). The length of ICU stay was similar between the groups. Discussion: ICU patients with Enterobacteriaceae infections de-escalated to ertapenem therapy had better outcomes compared to patients who remained on broad-spectrum, anti-pseudomonal therapy, suggesting that de-escalation is a safe approach amongst ICU patients.

Diagnosis and Treatment Recommendation and Exploration for Critical and Refractory Adverse Effects Related to Immunocheckpoint Inhibitors / 中国肺癌杂志

The application of immunological checkpoint inhibitors (ICIs) has modified many treatment strategies of malignant tumors, which has become a milestone in cancer therapy. The principle of action can be explained as "brake theory". After releasing the brakes by ICIs, unprecedented systemic toxicities, even some refractory and fatal immune-related adverse effects (irAEs) may develop. In this article, we summarized the recommended treatments of grade 3-4 severe irAEs in the latest European Society for Medical Oncology (ESMO), National Comprehensive Cancer Network (NCCN)/American Society of Clinical Oncology (ASCO), Society for Immunotherapy of Cancer (SITC) and Chinese Society of Clinical Oncology (CSCO) guidelines and consensus. We also performed a systemic review of case reports and reviews of irAEs up to May 20, 2019 in PubMed and Chinese journals. Successful applications of specific immunosuppressive drugs and stimulating factors beyond the above guidelines and consensus were supplemented and highlighted, including agents blocking interleukin 6 (IL-6), rituximab, anti-tumor necrosis factor-α (TNFα) monoclonal antibody (mAb), anti-integrin 4 mAb, Janus kinase inhibitors, thrombopoietin receptor agonists and antithymocyte globulin (ATG) etc. We put some concerns of using high-dose steroids for long-term, and emphasize the secondary infections, tumor progression, and unavailability of ICI re-challenge during steroid treatment. We propose the "De-escalation Therapy" principle for severe and refractory irAEs, and suggest that immunosuppressive drugs specifically targeting cytokines should be used as early as possible. Many irAEs in the era of immunotherapy are unprecedented compared with traditional chemotherapy and small-molecule targeted therapy, which is a big challenge to oncologists. Therefore, the establishment of multidisciplinary system is very important for the management of cancer patients.

Effect of bronchoalveolar lavage on the use of antibiotics in patients with severe pneumonia / 中华急诊医学杂志

Objective@#To investigate the difference between bronchoalveolar lavage fluid (BALF) and tracheal aspirate (TA) on the use of antibiotics in patients with severe pneumonia.@*Methods@#Patients with severe pneumonias admitted to the Department of General Intensive Care Unit of Second Affiliated Hospital of Zhejiang University School of Medicine, between December 2014 and March 2019 were retrospectively analyzed. The difference of effects of BLAF and TA on the use of antibiotics in patients with severe pneumonia were compared and analyzed, as well as the effects of antibiotic de-escalation on patient’s mortality were evaluated. The quantitative data were analyzed by independent sample t test, and the enumeration data were determined by Chi-square test or Fisher exact probability method.@*Results@#Among the 120 patients, more bacteria were detected in BALF than in TA (82 vs 60, P<0.05). More fungi were detected in BALF than in TA (20 vs 3, P<0.05). Compared with TA, BALF results were more likely to guide the adjustment of antibiotic regimens (41 vs 16, P<0.05), including guidance for antibiotics de-escalation (27 vs 9, P<0.05). There was no significant difference in the 14-day mortality, 28-day mortality, hospital stay and duration of mechanical ventilation between the two groups (all P<0.05).@*Conclusions@#Compared with TA, BALF, as a pathogens detection method for severe pneumania, has more advantages in guiding antibiotics administration, including antibiotic de-escalation, which will not increase the mortality of patients.

Effect of bronchoalveolar lavage on the use of antibiotics in patients with severe pneumonia / 中华急诊医学杂志

Objective To investigate the difference between bronchoalveolar lavage fluid(BALF)and tracheal aspirate(TA)on the use of antibiotics in patients with severe pneumonia.Methods Patients with severe pneumonias admitted to the Department of General Intensive Care Unit of Second Affiliated Hospital of Zhejiang University School of Medicine,between December 2014 and March 2019 were retrospectively analyzed.The difference of effects of BLAF and TA on the use of antibiotics in patients with severe pneumonia were compared and analyzed,as well as the effects of antibiotic de-escalation on patient's mortality were evaluated.The quantitative data were analyzed by independent sample t test and the enumeration data were determined by Chi-square test or Fisher exact probability method.Results Among the 120 patients more bacteria were detected in BALF than in TA(82 vs 60,P＜0.05).More fungi were detected in BALF than in TA(20 vs 3,P＜0.05).Compared with TA,BALF results were more likely to guide the adjustment of antibiotic regimens(41 vs 16,P＜0.05),including guidance for antibiotics de-escalation(27 vs 9,P＜0.05).There was no significant difference in the 14-day mortality,28-day mortality,hospital stay and duration of mechanical ventilation between the two groups(al P＜0.05).Conclusions Compared with TA,BALF,as a pathogens detection method for severe pneumonia,has more advantages in guiding antibiotics administration,including antibiotic de-escalation,which will not increase the mortality of patients.

Investigation on antimicrobial usage in 451 patients with complicated intra-abdominal infection / 中华急诊医学杂志

Objective To investigate the microbiological epidemiology and clinical use of antibiotics in patients complicated intra-abdominal infection (cIAI),therefore to optimize antibiotic use and to promote antimicrobial stewardship.Methods A total of 451 patients with cIAI from a Chinese tertiary hospital between January 2015 and December 2016 were retrospectively reviewed.The infection severity,timing of microbiological specimen sampling,culture results,initial antibiotic selection and later anti-infective regimen adjustment were analyzed.Results Three hundred and sixteen (70.1％,316/451) patients undergone microbiological investigation at infection sites within 3 days and 133 (42.1％) patients had a positive culture,of which 64.5％ were Enterobacteriaceae.Three hundred seventy-four patients (82.9％) initially received broad-spectrum antibiotics against gram-negative bacilli.Sixty-five patients (14.4％) initially received combined antibiotic therapy,of which 30.8％ were deemed as overuse.Among 308 patients who initially received broad-spectrum antibiotic therapy,268 patients (87.0％) clinically improved in five days,while de-escalation was only conducted in 72 cases (26.9％).On average,patients were treated with (2.29±1.30) antibiotics for a duration of (10.6±6.5) days,and 42.4％ received combined antibiotic therapy during hospitalization.Conclusions The major microbiological pathogens in cIAI patients in our hospital were Enterobacteriaceae.However,there are phenomena such as excessive usage with broad-spectrum antibiotics,insufficient awareness of de-escalation,and long course of anti-infective therapy,which needs to be further improved.

Role of de-escalation strategies in the treatment and prevention of chronic critical illness / 中华胃肠外科杂志

De-escalation strategy is the gradual transition of various complex, expensive, high-risk but effective treatments for critically ill patients to simple, safe, physiological but still effective ones. Chronic critical illness refers to patients suffering severe disease or surgical hit who later shift into a chronic state of relapse or even aggravation and stay in the intensive care unit for extended period. Risk factors for surgical related chronic critical illness include advanced age, malnutrition, multiple organ dysfunction and multiple hits. During the treatment of critically ill patients, the strategy of de-escalation therapy should always be implemented, including rational use of antibiotics, de-escalation of liquid therapy (i.e. de-resuscitation), timely removal of ventilator, rapid introduction and with drawal of continuous renal replacement measures, parenteral + enteral nutrition support therapy and timely cessation of sedation.

De-Escalation of P2Y₁₂ Receptor Inhibitor Therapy after Acute Coronary Syndromes in Patients Undergoing Percutaneous Coronary Intervention

Dual antiplatelet therapy (DAPT) — a combination of a P2Y₁₂ receptor inhibitor and aspirin — has revolutionized antithrombotic treatment. Potent P2Y₁₂ inhibitors such as prasugrel and ticagrelor exhibit a strong and more consistent platelet inhibition when compared to clopidogrel. Therefore, ticagrelor and prasugrel significantly reduce ischemic events, but at an expense of an increased bleeding risk in acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI). These observations have engaged intensive clinical research in alternative DAPT regimens to achieve sufficient platelet inhibition with an acceptable bleeding risk. Our review focusses on P2Y₁₂ receptor therapy de-escalation defined as a switch from a potent antiplatelet agent (ticagrelor or prasugrel) to clopidogrel. Recently, both unguided (platelet function testing independent) and guided (platelet function testing dependent) DAPT de-escalation strategies have been investigated in different clinical studies and both switching strategies could be possible options to prevent bleeding complications without increasing ischemic risk. In light of the still limited data currently available, future large-scale trials should accumulate more data on various DAPT de-escalation regimens with both ticagrelor and prasugrel in unguided and guided de-escalation approaches. In the current review we aim at summarizing and discussing the current evidence on this still emerging topic in the field of antiplatelet treatment.

Antibiotics De-Escalation in the Treatment of Ventilator-Associated Pneumonia in Trauma Patients: A Retrospective Study on Propensity Score Matching Method / 中华医学杂志(英文版)

<p><b>Background</b>Antimicrobial de-escalation refers to starting the antimicrobial treatment with broad-spectrum antibiotics, followed by narrowing the drug spectrum according to culture results. The present study evaluated the effect of de-escalation on ventilator-associated pneumonia (VAP) in trauma patients.</p><p><b>Methods</b>This retrospective study was conducted on trauma patients with VAP, who received de-escalation therapy (de-escalation group) or non-de-escalation therapy (non-de-escalation group). Propensity score matching method was used to balance the baseline characteristics between both groups. The 28-day mortality, length of hospitalization and Intensive Care Unit stay, and expense of antibiotics and hospitalization between both groups were compared. Multivariable analysis explored the factors that influenced the 28-day mortality and implementation of de-escalation.</p><p><b>Results</b>Among the 156 patients, 62 patients received de-escalation therapy and 94 patients received non-de-escalation therapy. No significant difference was observed in 28-day mortality between both groups (28.6% vs. 23.8%, P = 0.620). The duration of antibiotics treatment in the de-escalation group was shorter than that in the non-de-escalation group (11 [8-13] vs. 14 [8-19] days, P = 0.045). The expenses of antibiotics and hospitalization in de-escalation group were significantly lower than that in the non-de-escalation group (6430 ± 2730 vs. 7618 ± 2568 RMB Yuan, P = 0.043 and 19,173 ± 16,861 vs. 24,184 ± 12,039 RMB Yuan, P = 0.024, respectively). Multivariate analysis showed that high Acute Physiology and Chronic Health Evaluation II (APACHE II) score, high injury severity score, multi-drug resistant (MDR) infection, and inappropriate initial antibiotics were associated with patients' 28-day mortality, while high APACHE II score, MDR infection and inappropriate initial antibiotics were independent factors that prevented the implementation of de-escalation.</p><p><b>Conclusions</b>De-escalation strategy in the treatment of trauma patients with VAP could reduce the duration of antibiotics treatments and expense of hospitalization, without increasing the 28-day mortality and MDR infection.</p>

Tratamiento antimicrobiano específico de las infecciones quirúrgicas / Specific antimicrobial treatment of surgical infections

El paciente complicado con una infección quirúrgica requiere una terapia antibiótica integral con la colaboración del cirujano, del infectólogo y del microbiólogo. La selección inicial antimicrobiana es un punto clave que define la evolución posterior. La terapia de de-escalación permite disminuir el espectro de cobertura antimicrobiana inicial manteniendo el adecuado tratamiento para el paciente y disminuyendo la selección de microorganismos resistente. El uso adecuado de antimicrobianos comprende la selección inicial ajustada a la patología, la evaluación del riesgo individual e institucional a determinados gérmenes o mecanismos de resistencia, la elección de la dosis correcta, la de-escalación según el resultado bacteriológico y la reevaluación constante de la evolución para nuevo control del foco, ajuste o suspensión oportuna del esquema antimicrobiano(AU)

The complicated patient with a surgical infection requires comprehensive antibiotic therapy with the collaboration of the surgeon, the infectologist and the microbiologist. Initial antimicrobial selection is a key point that defines subsequent evolution. De-escalation therapy allows decreasing the initial antimicrobial coverage spectrum while maintaining proper treatment for the patient and reducing the selection of resistant microorganisms. The appropriate use of antimicrobials includes the initial selection adjusted to the pathology, the assessment of individual and institutional risk to certain germs or resistance mechanisms, the choice of the correct dose, the de-escalation according to the bacteriological result and the constant re-evaluation of the evolution for new control of the focus, adjustment or timely suspension of the antimicrobial scheme(AU)

Ventilator-associated pneumonia: the influence of bacterial resistance, prescription errors, and de-escalation of antimicrobial therapy on mortality rates

Abstract Ventilator-associated pneumonia is the most prevalent nosocomial infection in intensive care units and is associated with high mortality rates (14–70%). Aim This study evaluated factors influencing mortality of patients with Ventilator-associated pneumonia (VAP), including bacterial resistance, prescription errors, and de-escalation of antibiotic therapy. Methods This retrospective study included 120 cases of Ventilator-associated pneumonia admitted to the adult adult intensive care unit of the Federal University of Uberlândia. The chi-square test was used to compare qualitative variables. Student's t-test was used for quantitative variables and multiple logistic regression analysis to identify independent predictors of mortality. Findings De-escalation of antibiotic therapy and resistant bacteria did not influence mortality. Mortality was 4 times and 3 times higher, respectively, in patients who received an inappropriate antibiotic loading dose and in patients whose antibiotic dose was not adjusted for renal function. Multiple logistic regression analysis revealed the incorrect adjustment for renal function was the only independent factor associated with increased mortality. Conclusion Prescription errors influenced mortality of patients with Ventilator-associated pneumonia, underscoring the challenge of proper Ventilator-associated pneumonia treatment, which requires continuous reevaluation to ensure that clinical response to therapy meets expectations.

The application of de-escalation thinking shift mode in emergency condition of morning shift meeting / 中国实用护理杂志

Objective To explore the application effect of de-escalation thinking shift mode in emergency condition of morning shift meeting. Methods Guided by the de-escalation thinking, critical ill patients transfer tables were established in the emergency department, patients admitted into the emergency resuscitation room were selected from January 2015 to December 2015, and divided into the observation group (329 cases) and the control group ( 310 cases) . Patients in the control group applied the traditional oral shift meeting mode by the bed to check the patient; patients in the observation group applied the de-escalation thinking shift mode of morning shift meeting, followed by the specification of morning shift process and content; additionally, the cooperation of nursing staff, the transfer of nursing adverse events, nurses awareness of the patient′s condition, the patient satisfaction survey were counted before and after the implementation, respectively. Results Chinese version of Nursing Assessment Shift Report (NASR) was used to evaluate the cooperation status between the two sides of nursing staffs, and the mean scores of nursing staffs were 60.50±1.80 and 78.20±2.50 in the control group and the observation group, respectively, showing statistical significance (t=14.23, P<0.01);before application, corresponding statistical results regarding the shift meeting related nursing adverse events showed that there were 5 cases of infusion prolapse/leakage, 2 cases of pressure ulcer, 3 cases of pipe extrusion, and 2 cases of delayed drug delivery;after application, there were 2 cases of infusion prolapse/leakage, 0 case of pressure ulcer, 1 case of pipe extrusion, and 1 case of delayed drug delivery;comparison results showed significantly statistical difference (χ2=1.76-6.74, P<0.05). Before application, assessment results regarding the mean scores of nurses awareness of the patient's condition showed that mean scores of patients′ state of illness, test results, current treatment, potential risk, and nursing focus were 3.83 ± 0.62, 3.16 ± 0.64, 4.17 ± 0.36, 3.47 ± 1.26, and 3.64 ± 1.10, respectively;and after application, mean scores of patients′state of illness, test results, current treatment, potential risk, and nursing focus were 4.71 ± 0.27, 4.53±0.66, 4.89 ± 0.10, 4.50 ± 0.61, and 4.72 ± 0.43, respectively;the differences were statistically significant (t=-8.86--3.35, P<0.05). Furthermore, patient satisfaction with nursing staff in emergency department was improved from 91.6%(284/310) to 96.0%(316/329)(χ2 =25.74,P<0.05). Conclusions The application of de-escalation thinking shift mode in emergency condition of morning shift meeting may contribute to the specification of the transfer process, improvement of nursing work efficiency, and finally result in the promotion of patients′safety and teamwork.

Angry patient with fibromyalgia: Diagnosis and management in primary care

I report a case of 40-year-old lady who presented with symptoms and signs suggestive of fibromyalgia but was disregarded by attending doctor. She was infuriated and lodged a complaint to Family Medicine Specialist (FMS) whereby further assessment confirmed the diagnosis of fibromyalgia and subsequently treated in primary care setting.

Application effect of de-escalation thinking in craniocerebral injury complicated with cervical injury in emergency nursing / 中国实用护理杂志

Objective The aim of the study was to investigate the application effect of de-escalation thinking in first aid nursing of craniocerebral injury complicated with cervical spine injury.Methods 23 cases of craniocerebral injury and cervical spine injury patients received first aid rescue in emergency department of our hospital during the period from September 2012 to August 2014 were set as the observation group,and the de-escalation thinking way was used during rescue process.19 cases of craniocerebral injury and cervical spine injury patients during the period from September 2010 to August 2012 were set as the control group,traditional way of clinical experience thinking way was used.The early warning time,emergency treatment time and missed diagnosis cases were compared between the two groups.Results The early warning time of diagnosed as traumatic brain injury complicated with cervical spine injury (t=18.035) and emergency treatment time (t=7.650) in the observation group were shorter than those of the control group,the difference was significant.The missed diagnosis rate of the observation group [4.35％(1/23)] was significantly lower than that of the control group (9/19),the difference was significant (x2=8.38).Conclusions Application of de-escalation thinking mode in rescue by emergency nurses can shorten the early warning and emergency treatment time,decrease the missed diagnosis rate and improve the timeliness of the rescue for craniocerebral injury complicated with cervical spine injury.

Treatment strategy for pediatric infectious diseases / 中华实用儿科临床杂志

The widespread use of antibiotics has been effectively controlled serious life-threatening infections.The trituration,exploitation and use of antibiotics has been rapidly developed and applied to many fields.Due to the extensive use of various antibiotics,the emergences of drug-resistant bacteria and the rates of bacterial resistance have increased unceasingly which has been a common focus in the world.Resistant pathogen can reduce the effectiveness of antibiotics,and which is a serious threat to human health.De-escalation therapy of antibiotics can quickly and effectively control serious infections,and avoid bacterial resistance,and induce fungal infections.The rational use of antibiotics in pediatrics is very imperative,which includes strengthening management of antibiotics,and improving awareness and vigilance of the adverse reactions of antibiotics,and consummating specification of medication.Then,realize the correct,safe,rational medication of antibiotics.

Survey on de-escalation of empiric broad-spectrum antibiotics treatment for patients in intensive care unit / 中华临床感染病杂志

Objective To investigate de-escalation of empiric broad-spectrum antibiotics treatment for patients in intensive care unit (ICU).Methods Data of the patients discharged from ICU in the Second Affiliated Hospital of Zhejiang University from July 1 to December 31 of 2012 and from July 1 to December 31 of 2013 were retrospectively reviewed.Patients with initial use of empirical broad-spectrum antibiotics within 3 d after ICU admission were included in the study.Clinical data including status of infection,the initial empiric antimicrobial therapy,pathogens culture and adjustment of antibiotics in 5 days were analyzed.Results A total of 841 patients were discharged from ICU during the study periods and antibiotics were used in 786 (93.5％) patients.Among 786 patients,389 (49.5％) were treated empirically with broad-spectrum antibiotics,but only 269 (69.2％) had evidences of bacterial infections.Of the 389 patients with empiric antibiotics use,de-escalation of antibiotics was applied only in 6 (1.54％) patients within 5 days after the initiation of treatment.In 269 patients with evidence of infection,specimen sampling and culture were performed in 248 (92.2％) patients within 3 days,among which 165 samples were positive,and the clinical isolates were mainly multi-drug resistant gram negative bacilli and colonized bacteria in oropharyngeal cavity.De-escalation was applied only in 4 (1.49％,4/269) patients with evidences of bacterial infections.Conclusion Broad-spectrum antibiotics as initial empiric therapy is common for patients in ICU,however de-escalation of empiric therapy is rarely applied even in patients with positive results in pathogen isolation and culture.