title: Initial use of one or two antibiotics for critically ill patients with community-acquired pneumonia: impact on survival and bacterial resistance.
abstract: BACKGROUND
  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 impact on 60-day mortality of using one or two antibiotics. We also compared the rates of nosocomial pneumonia and multidrug-resistant bacteria.
  
  
  METHODS
  This 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.
  
  
  RESULTS
  Initial 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.
  
  
  CONCLUSIONS
  Initial 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.
authors.forename: Christophe
authors.initials: C
authors.lastname: Adrie
authors.forename: Carole
authors.initials: C
authors.lastname: Schwebel
authors.forename: Maïté
authors.initials: M
authors.lastname: Garrouste-Orgeas
authors.forename: Lucile
authors.initials: L
authors.lastname: Vignoud
authors.forename: Benjamin
authors.initials: B
authors.lastname: Planquette
authors.forename: Elie
authors.initials: E
authors.lastname: Azoulay
authors.forename: Hatem
authors.initials: H
authors.lastname: Kallel
authors.forename: Michael
authors.initials: M
authors.lastname: Darmon
authors.forename: Bertrand
authors.initials: B
authors.lastname: Souweine
authors.forename: Anh-Tuan
authors.initials: AT
authors.lastname: Dinh-Xuan
authors.forename: Samir
authors.initials: S
authors.lastname: Jamali
authors.forename: Jean-Ralph
authors.initials: JR
authors.lastname: Zahar
authors.forename: Jean-François
authors.initials: JF
authors.lastname: Timsit
mesh_terms: D000368:Aged; D000900:Anti-Bacterial Agents / Q000008:administration & dosage / Q000627:therapeutic use; D017714:Community-Acquired Infections / Q000188:drug therapy* / Q000382:microbiology / Q000401:mortality; D016638:Critical Illness; D003428:Cross Infection / Q000453:epidemiology; D024901:Drug Resistance, Multiple, Bacterial; D004359:Drug Therapy, Combination; D005260:Female; D024841:Fluoroquinolones / Q000008:administration & dosage / Q000627:therapeutic use*; D005602:France / Q000453:epidemiology; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data; D018942:Macrolides / Q000008:administration & dosage / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D018410:Pneumonia, Bacterial / Q000188:drug therapy* / Q000382:microbiology / Q000401:mortality; D011446:Prospective Studies; D018570:Risk Assessment; D016019:Survival Analysis; D013997:Time Factors; D047090:beta-Lactams / Q000008:administration & dosage / Q000627:therapeutic use*
chemical_list: D000900:Anti-Bacterial Agents; D024841:Fluoroquinolones; D018942:Macrolides; D047090:beta-Lactams