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Initial use of one or two antibiotics for critically ill patients with community-acquired pneumonia: impact on survival and bacterial resistance.
Crit Care. 2013 Nov 7;17(6):R265
Authors: Adrie C, Schwebel C, Garrouste-Orgeas M, Vignoud L, Planquette B, Azoulay E, Kallel H, Darmon M, Souweine B, Dinh-Xuan AT, Jamali S, Zahar JR, Timsit JF
Abstract
INTRODUCTION: 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: 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.
RESULTS: Initial adequate antibiotic therapy was significantly associated with better survival (subdistribution hazard ratio [sHR], 0.63; 95% confidence interval [95%CI], 0.42-0.94; P = 0.02); this effect was strongest in patients with Streptococcus pneumonia CAP (sHR, 0.05; 95%CI, 0.005-0.46; P = 0.001) or septic shock (sHR:0.62; 95%CI,0.38-0.1.00; 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 (beta-lactam) and either of the two dual-therapy groups (beta-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.
PMID: 24200097 [PubMed - as supplied by publisher]