抗生素的降阶梯治疗（de-escalation therapy）是近年来提出的用于治疗重症肺部感染的一个策略，在临床研究和实践中能够有效地提高重症感染治疗的成功率，降低病死率，同时降低住院时间和费用，是感染治疗策略的一大进展。本文就这一策略的概念演变和应用时机作一介绍
Objective To investigate whether de-escalation antibacterial therapy would be helpful to antifungal treatment in patients with invasive pulmonary fungal infection( IPFI) .Methods A prospective study was conducted in 174 IPFI patients( male 106, female 68) in the Second Hospital of Hebei Medical University from January 2008 to July 2010. The clinical data was collected including symptoms, physical signs,microbiological results, treatment and prognosis, etc. The therapeutic results were compared between the patients who received or did not receive de-escalation antibacterial therapy. Results The predominant pathogenic fungus was Candida albicans, which accounted for 59. 7% of IPFI. The effect of antifungal therapy showed statistically significant difference between the patients who received de-escalation antibacterial therapy and the patients who did not ( 60. 0% vs. 34. 5% , P =0. 001) . Conclusion The deescalation use of antibacterial therapy would be helpful to antifungal efficacy.
Objectives To systematically review the efficacy and safety of de-escalation therapy for severe pneumonia. Methods We searched PubMed, EMbase, The Cochrane Library, CBM, CNKI, VIP and WanFang Data databases and the Chinese Clinical Trial Registry (www.chictr.org.cn) to collect randomized controlled trials (RCTs) of de-escalation therapy for patients with severe pneumonia from inception to June, 2017. Two reviewers independently screened literature, extracted data and assessed the risk of bias of included studies. Meta-analysis was then performed using RevMan 5.3 software. Results A total of 13 RCTs involving 1 860 patients were included. The results of meta-analysis showed that: the de-escalation therapy group was superior to the control group on clinical cure rate (RR=1.28, 95%CI 1.20 to 1.35, P<0.000 01), the total hospitalization time (MD=–6.86, 95%CI –9.12 to –4.59,P<0.000 01), remission time of complications (MD=–6.26, 95%CI –8.43 to –4.10,P<0.000 01) and mortality (RR=0.48, 95%CI 0.28 to 0.82,P=0.001). Reported cases of adverse reactions were rare, in which the degree of reactions ranged from mild to moderate. The safety was fairly satisfactory. Conclusions Current evidence shows that de-escalation therapy for patients with severe pneumonia has improved efficacy compared with conventional treatments, and can significantly shorten the total hospitalization time and reduce mortality. Due to the limited quality and quantity of the included studies, more high quality studies are required to verify above conclusions.