Combination antibiotic therapy with macrolides improves survival in intubated patients with community-acquired pneumonia

• DOI: 10.1007/s00134-009-1730-y
• Publication Date: 2009-12-01T07:09:46Z
• Authors: I. Martin-Loeches; T. Lisboa; A. Rodriguez; C. Putensen; D. Annane; J. Garnacho-Montero; M. I. Restrepo; J. Rello
• Keywords: Male; Chi-Square Distribution; Pneumonia; Middle Aged; Severity of Illness Index; 3. Good health; Community-Acquired Infections; Europe; Intensive Care Units; 03 medical and health sciences; 0302 clinical medicine; Risk Factors; Sepsis; Intubation, Intratracheal; Humans; Drug Therapy, Combination; Female; Guideline Adherence; Macrolides; Prospective Studies; APACHE; Fluoroquinolones; Proportional Hazards Models

To assess the effect on survival of macrolides or fluoroquinolones in intubated patients admitted to the intensive care unit (ICU) with severe community-acquired pneumonia (severe CAP).Prospective, observational cohort, multicenter study conducted in 27 ICUs of 9 European countries. Two hundred eighteen consecutive patients requiring invasive mechanical ventilation for an admission diagnosis of CAP were recruited.Severe sepsis and septic shock were present in 165 (75.7%) patients. Microbiological documentation was obtained in 102 (46.8%) patients. ICU mortality was 37.6% (n = 82). Non-survivors were older (58.6 +/- 16.1 vs. 63.4 +/- 16.7 years, P < 0.05) and presented a higher score on the simplified Acute Physiology Score II at admission (45.6 +/- 15.4 vs. 50.8 +/- 17.5, P < 0.05). Monotherapy was given in 43 (19.7%) and combination therapy in 175 (80.3%) patients. Empirical antibiotic therapy was in accordance with the 2007 Infectious Diseases Society of America (IDSA)/American Thoracic Society (ATS) guidelines in 100 (45.9%) patients (macrolides in 46 patients and fluoroquinolones in 54). In this cohort, a Cox regression analysis adjusted by severity identified that macrolide use was associated with lower ICU mortality (hazard ratio, HR 0.48, confidence intervals, 95% CI 0.23-0.97, P = 0.04) when compared to the use of fluoroquinolones. When more severe patients presenting severe sepsis and septic shock were analyzed (n = 92), similar results were obtained (HR 0.44, 95% CI 0.20-0.95, P = 0.03).Patients with severe community-acquired pneumonia had a low adherence with the 2007 IDSA/ATS guidelines. Combination therapy with macrolides should be preferred in intubated patients with severe CAP.