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Abstract
IntroductionSeveral guidelines recommend initial empirical treatment with two antibiotics instead of one to decrease mortality in community-acquired pneumonia (CAP) requiring intensive-care-unit (ICU) admission. We compared the impact on 60-day mortality of using one or two antibiotics. We also compared the rates of nosocomial pneumonia and multidrug-resistant bacteria.MethodsThis is an observational cohort study of 956 immunocompetent patients with CAP admitted to ICUs in France and entered into a prospective database between 1997 and 2010.Patients with chronic obstructive pulmonary disease were excluded. Multivariate analysis adjusted for disease severity, gender, and co-morbidities was used to compare the impact on 60-day mortality of receiving adequate initial antibiotics and of receiving one versus two initial antibiotics.ResultsInitial adequate antibiotic therapy was significantly associated with better survival (subdistribution hazard ratio (sHR), 0.63; 95% confidence interval (95% CI), 0.42 to 0.94; P = 0.02); this effect was strongest in patients with Streptococcus pneumonia CAP (sHR, 0.05; 95% CI, 0.005 to 0.46; p = 0.001) or septic shock (sHR: 0.62; 95% CI 0.38 to 1.00; p = 0.05). Dual therapy was associated with a higher frequency of initial adequate antibiotic therapy. However, no difference in 60-day mortality was found between monotherapy (β-lactam) and either of the two dual-therapy groups (β-lactam plus macrolide or fluoroquinolone). The rates of nosocomial pneumonia and multidrug-resistant bacteria were not significantly different across these three groups.ConclusionsInitial adequate antibiotic therapy markedly decreased 60-day mortality. Dual therapy improved the likelihood of initial adequate therapy but did not predict decreased 60-day mortality. Dual therapy did not increase the risk of nosocomial pneumonia or multidrug-resistant bacteria.
Highlights
Several guidelines recommend initial empirical treatment with two antibiotics instead of one to decrease mortality in community-acquired pneumonia (CAP) requiring intensive-care-unit (ICU) admission
In conclusion, initial adequate therapy was associated with better 60-day survival in our patients with CAP requiring ICU admission and without chronic obstructive pulmonary disease (COPD) or immunodeficiency
Dual therapy did not increase the risks of nosocomial pneumonia or secondary bacterial multidrug resistance
Summary
Several guidelines recommend initial empirical treatment with two antibiotics instead of one to decrease mortality in community-acquired pneumonia (CAP) requiring intensive-care-unit (ICU) admission. We compared the rates of nosocomial pneumonia and multidrug-resistant bacteria. Community-acquired pneumonia (CAP) is among the most common severe infections in critically ill patients [1] and is associated with a high death toll. Failure to use adequate antibiotics (that is, antibiotics active in vitro on the causative organism) considerably increases the risk of death, in patients with severe sepsis [2,3]. Our primary objective in this observational cohort study of a prospective database was to determine whether using two initial antibiotics instead of one improved 60-day mortality in patients admitted to the ICU for CAP. The risks of nosocomial pneumonia and multidrug-resistant (MDR) bacteria were compared in patients given one versus two antibiotics
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