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


METHODS
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.


RESULTS
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).


CONCLUSIONS
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.
Martin-Loeches
I
I
Critical Care Department, Mater Misericordiae University Hospital, Dublin, Ireland.
Lisboa
T
T
Rodriguez
A
A
Putensen
C
C
Annane
D
D
Garnacho-Montero
J
J
Restrepo
M I
MI
Rello
J
J
D018806:APACHE; D016009:Chi-Square Distribution; D017714:Community-Acquired Infections / Q000188:drug therapy* / Q000453:epidemiology; D004359:Drug Therapy, Combination; D005060:Europe / Q000453:epidemiology; D005260:Female; D024841:Fluoroquinolones / Q000627:therapeutic use; D019983:Guideline Adherence; D006801:Humans; D007362:Intensive Care Units; D007442:Intubation, Intratracheal; D018942:Macrolides / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D011014:Pneumonia / Q000188:drug therapy* / Q000453:epidemiology; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012307:Risk Factors; D018805:Sepsis / Q000453:epidemiology; D012720:Severity of Illness Index; D012772:Shock, Septic / Q000453:epidemiology; D018709:Statistics, Nonparametric; D015996:Survival Rate
D024841:Fluoroquinolones; D018942:Macrolides