Medline ® Abstracts for References 52-54
of 'Treatment of community-acquired pneumonia in adults who require hospitalization'
Combination antibiotic therapy improves survival in patients with community-acquired pneumonia and shock.
Rodríguez A, Mendia A, Sirvent JM, Barcenilla F, de la Torre-Prados MV, Solé-Violán J, Rello J, CAPUCI Study Group
Crit Care Med. 2007;35(6):1493.
OBJECTIVE: To assess whether combination antibiotic therapy improves outcome of severe community-acquired pneumonia in the subset of patients with shock.
DESIGN: Secondary analysis of a prospective observational, cohort study.
SETTING: Thirty-three intensive care units (ICUs) in Spain.
PATIENTS: Patients were 529 adults with community-acquired pneumonia requiring ICU admission.
MEASUREMENT AND MAIN RESULTS: Two hundred and seventy (51%) patients required vasoactive drugs and were categorized as having shock. The effects of combination antibiotic therapy and monotherapy on survival were compared using univariate analysis and a Cox regression model. The adjusted 28-day in-ICU mortality was similar (p = .99) for combination antibiotic therapy and monotherapy in the absence of shock. However, in patients with shock, combination antibiotic therapy was associated with significantly higher adjusted 28-day in-ICU survival (hazard ratio, 1.69; 95% confidence interval, 1.09-2.60; p = .01) in a Cox hazard regression model. Even when monotherapy was appropriate, it achieved a lower 28-day in-ICU survival than an adequate antibiotic combination (hazard ratio, 1.64; 95% confidence interval, 1.01-2.64).
CONCLUSIONS: Combination antibiotic therapy does not seem to increase ICU survival in all patients with severe community-acquired pneumonia. However, in the subset of patients with shock, combination antibiotic therapy improves survival rates.
Intensive Care Unit, Joan XXIII University Hospital, Tarragona, Spain.
Addition of a macrolide to a beta-lactam-based empirical antibiotic regimen is associated with lower in-hospital mortality for patients with bacteremic pneumococcal pneumonia.
Martínez JA, Horcajada JP, Almela M, Marco F, Soriano A, García E, Marco MA, Torres A, Mensa J
Clin Infect Dis. 2003;36(4):389.
To assess the association between inclusion of a macrolide in a beta-lactam-based empirical antibiotic regimen and mortality among patients with bacteremic pneumococcal pneumonia, 10 years of data from a database were analyzed. The total available set of putative prognostic factors was subjected to stepwise logistic regression, with in-hospital death as the dependent variable. Of the 409 patients analyzed, 238 (58%) received a beta-lactam plus a macrolide and 171 (42%) received a beta-lactam without a macrolide. Multivariate analysis revealed 4 variables to be independently associated with death: shock (P<.0001), age of>or=65 years (P=.02), infections with pathogens that have resistance to both penicillin and erythromycin (P=.04), and no inclusion of a macrolide in the initial antibiotic regimen (P=.03). For patients with bacteremic pneumococcal pneumonia, not adding a macrolide to a beta-lactam-based initial antibiotic regimen is an independent predictor of in-hospital mortality. However, only a randomized study can definitively determine whether this association is due to a real effect of macrolides.
Institut Clínic Infeccions i Immunologia, Hospital Clinic Universitari, Barcelona, Spain. firstname.lastname@example.org
Antibiotics for bacteremic pneumonia: Improved outcomes with macrolides but not fluoroquinolones.
Metersky ML, Ma A, Houck PM, Bratzler DW
BACKGROUND: The questions of whether the use of antibiotics that are active against atypical organisms is beneficial in the treatment of community-acquired pneumonia and of the potential mechanisms of any beneficial effects remain unresolved. Proposed mechanisms include activity against atypical organisms vs the immunomodulatory effects of these antibiotics. The study of outcomes of a large cohort of patients with bacteremic pneumonia provides a unique opportunity to address these questions by excluding patients with primary atypical infection.
METHODS: We reviewed data from the charts of 2,209 Medicare patients who were admitted to hospitals across the United States from either home or a nursing facility with bacteremic pneumonia between 1998 and 2001. Patients were stratified according to the type of antibiotic treatment. Multivariate modeling was performed to assess the relationship between the class of antibiotic used and several outcome variables.
RESULTS: The initial use of any antibiotic active against atypical organisms was independently associated with a decreased risk of 30-day mortality (odds ratio [OR], 0.76; 95% confidence interval [CI], 0.59 to 0.98; p = 0.03) and hospital admission within 30 days of discharge (OR, 0.67; 95% CI, 0.51 to 0.89; p = 0.02). Further analysis revealed that the benefits of atypical treatment were associated with the use of macrolides, but not the use of fluoroquinolones or tetracyclines, with macrolides conferring lower risks of in-hospital mortality (OR, 0.59; 95% CI, 0.40 to 0.88; p = 0.01), 30-day mortality (OR, 0.61; 95% CI, 0.43 to 0.87; p = 0.007), and hospital readmission within 30 days of discharge (OR, 0.59; 95% CI, 0.42 to 0.85; p = 0.004).
CONCLUSIONS: Initial antibiotic treatment including a macrolide agent is associated with improved outcomes in Medicare patients hospitalized with bacteremic pneumonia. These results have implications regarding the mechanism by which the use of a macrolide for treatment of pneumonia is associated with improved outcomes.
Division of Pulmonary and Critical Care Medicine, University of Connecticut Health Center, 263 Farmington Ave, Farmington, CT 06030-1321, USA. Metersky@nso.uchc.edu