Antibiotic de-escalation patterns and outcomes in critically ill patients with suspected pneumonia as informed by bronchoalveolar lavage results

The N. U. SCRIPT Study Investigators

doi:10.1007/s10096-025-05144-2

Antibiotic de-escalation patterns and outcomes in critically ill patients with suspected pneumonia as informed by bronchoalveolar lavage results

The N. U. SCRIPT Study Investigators

Medicine, Pulmonary Division

Research output: Contribution to journal › Article › peer-review

Abstract

Purpose: Antibiotic stewardship in critically ill pneumonia patients is crucial yet challenging, partly due to the limitations of noninvasive diagnostic tests. This study reports an antibiotic de-escalation pattern informed by bronchoalveolar lavage (BAL) results, incorporating quantitative cultures and multiplex PCR rapid diagnostic tests. Methods: We analyzed data from SCRIPT, a single-center prospective cohort study of mechanically ventilated patients who underwent a BAL for suspected pneumonia. We used the Narrow Antibiotic Therapy (NAT) score to quantify day-by-day antibiotic prescription patterns for each suspected pneumonia episode etiology (bacterial, viral, mixed bacterial/viral, microbiology-negative, and non-pneumonia control). The primary outcome was a composite of in-hospital mortality, discharge to hospice, or requiring lung transplantation during hospitalization, which we referred to as unfavorable outcomes. The secondary outcomes were duration of ICU stay, duration of intubation, and Clostridium difficile during admission. Outcomes were compared across pneumonia etiologies with the Mann–Whitney U test and Fisher’s exact test. Results: Among 686 patients (409 men, 276 women) with 927 pneumonia episodes, NAT score analysis showed consistent antibiotic de-escalation in all pneumonia etiologies except resistant bacterial pneumonia. Microbiology-negative pneumonia was treated similarly to susceptible bacterial pneumonia. 44% viral episodes had antibiotic cessation by post-BAL day 5. Unfavorable outcomes were comparable across all pneumonia etiologies. Patients with viral and mixed bacterial/viral pneumonia had longer durations of ICU stay and intubation. Clostridium difficile was detected in 14 (2%) patients. Conclusions: BAL quantitative cultures and multiplex PCR rapid diagnostic tests resulted in prompt antibiotic de-escalation in critically ill pneumonia patients. There was no evidence of increased unfavorable outcomes.

Original language	English (US)
Journal	European Journal of Clinical Microbiology and Infectious Diseases
DOIs	https://doi.org/10.1007/s10096-025-05144-2
State	Accepted/In press - 2025

Funding

SCRIPT is supported by NIH/NIAID U19 AI135964. CAG is supported by NIH/NHLBI K23HL169815, a Parker B. Francis Opportunity Award, and an ATS Unrestricted Grant. BDS is supported by the NIH (R01HL149883, R01HL153122, P01HL154998, P01 AG049665, and U19 AI135964). RGW is supported by NIH grants U19 AI135964, U01 TR003528, P01HL154998, R01HL149883, R01LM013337. CIP is supported by NIAID (U19 AI135964), Northwestern University Clinical and Translational Sciences Institute (5 KL2 TR001424-09). The funding sources did not have a role in the design, execution, or prior review of the study or in the data presented in this manuscript. Opinions expressed in this work do not necessarily reflect those of the funding sources.

Keywords

Antibiotic stewardship
Bronchoalveolar lavage
Microbiology-negative pneumonia
Multiplex PCR

ASJC Scopus subject areas

Microbiology (medical)
Infectious Diseases

UN SDGs

This output contributes to the following UN Sustainable Development Goals (SDGs)

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10.1007/s10096-025-05144-2

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title = "Antibiotic de-escalation patterns and outcomes in critically ill patients with suspected pneumonia as informed by bronchoalveolar lavage results",

abstract = "Purpose: Antibiotic stewardship in critically ill pneumonia patients is crucial yet challenging, partly due to the limitations of noninvasive diagnostic tests. This study reports an antibiotic de-escalation pattern informed by bronchoalveolar lavage (BAL) results, incorporating quantitative cultures and multiplex PCR rapid diagnostic tests. Methods: We analyzed data from SCRIPT, a single-center prospective cohort study of mechanically ventilated patients who underwent a BAL for suspected pneumonia. We used the Narrow Antibiotic Therapy (NAT) score to quantify day-by-day antibiotic prescription patterns for each suspected pneumonia episode etiology (bacterial, viral, mixed bacterial/viral, microbiology-negative, and non-pneumonia control). The primary outcome was a composite of in-hospital mortality, discharge to hospice, or requiring lung transplantation during hospitalization, which we referred to as unfavorable outcomes. The secondary outcomes were duration of ICU stay, duration of intubation, and Clostridium difficile during admission. Outcomes were compared across pneumonia etiologies with the Mann–Whitney U test and Fisher{\textquoteright}s exact test. Results: Among 686 patients (409 men, 276 women) with 927 pneumonia episodes, NAT score analysis showed consistent antibiotic de-escalation in all pneumonia etiologies except resistant bacterial pneumonia. Microbiology-negative pneumonia was treated similarly to susceptible bacterial pneumonia. 44\% viral episodes had antibiotic cessation by post-BAL day 5. Unfavorable outcomes were comparable across all pneumonia etiologies. Patients with viral and mixed bacterial/viral pneumonia had longer durations of ICU stay and intubation. Clostridium difficile was detected in 14 (2\%) patients. Conclusions: BAL quantitative cultures and multiplex PCR rapid diagnostic tests resulted in prompt antibiotic de-escalation in critically ill pneumonia patients. There was no evidence of increased unfavorable outcomes.",

keywords = "Antibiotic stewardship, Bronchoalveolar lavage, Microbiology-negative pneumonia, Multiplex PCR",

author = "\{The N. U. SCRIPT Study Investigators\} and Mengou Zhu and Pickens, \{Chiagozie I.\} and Markov, \{Nikolay S.\} and Anna Pawlowski and Mengjia Kang and Rasmussen, \{Luke V.\} and Walter, \{James McCauley\} and Nadig, \{Nandita R.\} and Singer, \{Benjamin D\} and Wunderink, \{Richard G.\} and Gao, \{Catherine A\}",

note = "Publisher Copyright: {\textcopyright} The Author(s) 2025.",

year = "2025",

doi = "10.1007/s10096-025-05144-2",

language = "English (US)",

journal = "European Journal of Clinical Microbiology and Infectious Diseases",

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T1 - Antibiotic de-escalation patterns and outcomes in critically ill patients with suspected pneumonia as informed by bronchoalveolar lavage results

AU - The N. U. SCRIPT Study Investigators

AU - Zhu, Mengou

AU - Pickens, Chiagozie I.

AU - Markov, Nikolay S.

AU - Pawlowski, Anna

AU - Kang, Mengjia

AU - Rasmussen, Luke V.

AU - Walter, James McCauley

AU - Nadig, Nandita R.

AU - Singer, Benjamin D

AU - Wunderink, Richard G.

AU - Gao, Catherine A

PY - 2025

Y1 - 2025

N2 - Purpose: Antibiotic stewardship in critically ill pneumonia patients is crucial yet challenging, partly due to the limitations of noninvasive diagnostic tests. This study reports an antibiotic de-escalation pattern informed by bronchoalveolar lavage (BAL) results, incorporating quantitative cultures and multiplex PCR rapid diagnostic tests. Methods: We analyzed data from SCRIPT, a single-center prospective cohort study of mechanically ventilated patients who underwent a BAL for suspected pneumonia. We used the Narrow Antibiotic Therapy (NAT) score to quantify day-by-day antibiotic prescription patterns for each suspected pneumonia episode etiology (bacterial, viral, mixed bacterial/viral, microbiology-negative, and non-pneumonia control). The primary outcome was a composite of in-hospital mortality, discharge to hospice, or requiring lung transplantation during hospitalization, which we referred to as unfavorable outcomes. The secondary outcomes were duration of ICU stay, duration of intubation, and Clostridium difficile during admission. Outcomes were compared across pneumonia etiologies with the Mann–Whitney U test and Fisher’s exact test. Results: Among 686 patients (409 men, 276 women) with 927 pneumonia episodes, NAT score analysis showed consistent antibiotic de-escalation in all pneumonia etiologies except resistant bacterial pneumonia. Microbiology-negative pneumonia was treated similarly to susceptible bacterial pneumonia. 44% viral episodes had antibiotic cessation by post-BAL day 5. Unfavorable outcomes were comparable across all pneumonia etiologies. Patients with viral and mixed bacterial/viral pneumonia had longer durations of ICU stay and intubation. Clostridium difficile was detected in 14 (2%) patients. Conclusions: BAL quantitative cultures and multiplex PCR rapid diagnostic tests resulted in prompt antibiotic de-escalation in critically ill pneumonia patients. There was no evidence of increased unfavorable outcomes.

AB - Purpose: Antibiotic stewardship in critically ill pneumonia patients is crucial yet challenging, partly due to the limitations of noninvasive diagnostic tests. This study reports an antibiotic de-escalation pattern informed by bronchoalveolar lavage (BAL) results, incorporating quantitative cultures and multiplex PCR rapid diagnostic tests. Methods: We analyzed data from SCRIPT, a single-center prospective cohort study of mechanically ventilated patients who underwent a BAL for suspected pneumonia. We used the Narrow Antibiotic Therapy (NAT) score to quantify day-by-day antibiotic prescription patterns for each suspected pneumonia episode etiology (bacterial, viral, mixed bacterial/viral, microbiology-negative, and non-pneumonia control). The primary outcome was a composite of in-hospital mortality, discharge to hospice, or requiring lung transplantation during hospitalization, which we referred to as unfavorable outcomes. The secondary outcomes were duration of ICU stay, duration of intubation, and Clostridium difficile during admission. Outcomes were compared across pneumonia etiologies with the Mann–Whitney U test and Fisher’s exact test. Results: Among 686 patients (409 men, 276 women) with 927 pneumonia episodes, NAT score analysis showed consistent antibiotic de-escalation in all pneumonia etiologies except resistant bacterial pneumonia. Microbiology-negative pneumonia was treated similarly to susceptible bacterial pneumonia. 44% viral episodes had antibiotic cessation by post-BAL day 5. Unfavorable outcomes were comparable across all pneumonia etiologies. Patients with viral and mixed bacterial/viral pneumonia had longer durations of ICU stay and intubation. Clostridium difficile was detected in 14 (2%) patients. Conclusions: BAL quantitative cultures and multiplex PCR rapid diagnostic tests resulted in prompt antibiotic de-escalation in critically ill pneumonia patients. There was no evidence of increased unfavorable outcomes.

KW - Antibiotic stewardship

KW - Bronchoalveolar lavage

KW - Microbiology-negative pneumonia

KW - Multiplex PCR

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JO - European Journal of Clinical Microbiology and Infectious Diseases

JF - European Journal of Clinical Microbiology and Infectious Diseases

ER -

Antibiotic de-escalation patterns and outcomes in critically ill patients with suspected pneumonia as informed by bronchoalveolar lavage results

Abstract

Funding

Keywords

ASJC Scopus subject areas

UN SDGs

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