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

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Abstract

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.

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Acknowledgments

The EU-VAP/CAP Study is endorsed by the European Critical Care Research Network (ECCRN). This study has been supported in part by grants from CIBER Enfermedades Respiratorias (CIBERES 37706/06/0036) by Carlos III Health Institute and FISS 04/1500. Dr. Restrepo is supported by a Department of Veteran Affairs Veterans Integrated Service Network 17 new faculty grant and National Health Institute grant KL2 RR025766.

Conflict of interest statement

The authors declare no conflict of interest regarding this manuscript.

Author information

Authors and Affiliations

  1. Critical Care Department, Mater Misericordiae University Hospital, Dublin, Ireland

    I. Martin-Loeches

  2. Critical Care Department, Joan XXIII University Hospital, University Rovira i Virgili, IISPV, CIBER Enfermedades Respiratorias (CIBERES), Mallafré Guasch 4, 43007, Tarragona, Spain

    I. Martin-Loeches, T. Lisboa, A. Rodriguez & J. Rello

  3. Department of Anesthesiology and Intensive Care Medicine, University of Bonn, Bonn, Germany

    C. Putensen

  4. Service de Réanimation, Hôpital Raymond Poincaré (AP-HP), Université de Versailles SQY, Paris, France

    D. Annane

  5. Critical Care and Emergency Department, Hospital Universitario Virgen del Rocio, Sevilla, Spain

    J. Garnacho-Montero

  6. Department of Medicine, Division of Pulmonary and Critical Care Medicine, VERDICT, South Texas Veterans Health Care System, Audie L Murphy Division, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA

    M. I. Restrepo

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  1. I. Martin-Loeches
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  8. J. Rello
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Corresponding author

Correspondence to J. Rello.

Additional information

For the EU-VAP/CAP Study Group.

This article is discussed in the editorial available at: doi:10.1007/s00134-009-1734-7.

Appendix

Appendix

The EU-VAP/CAP Study Group: Djilali Annane (Raymond Poincaré University Hospital, Garches, France), Rosario Amaya-Villar (Virgen de Rocio University Hospital, Seville, Spain), Apostolos Armaganidis (Attikon University Hospital, Athens, Greece), Stijn Blot (Ghent University Hospital, Ghent, Belgium), Christian Brun-Buisson (Henri-Mondor University Hospital, Paris, France), Antonio Carneiro (Santo Antonio Hospital, Porto, Portugal), Maria Deja (Charité University Hospital, Berlin, Germany), Jan DeWaele (Ghent University Hospital, Ghent, Belgium), Emili Diaz (Joan XIII University Hospital, Tarragona, Catalonia), George Dimopoulos (Attikon University Hospital and Sotiria Hospital, Athens, Greece), Silvano Gardellino (Cardinal Massaia Hospital, Asti, Italy), Jose Garnacho-Montero (Virgen de Rocio University Hospital, Seville, Spain), Mustafa Guven (Erciyes University Hospital, Kayseri, Turkey), Apostolos Komnos (Larisa Hospital, Larisa, Greece), Despona Koulenti (Attikon University Hospital, Athens, Greece and Rovira i Virgili University, Tarragona, Spain), Wolfgang Krueger (Tuebingen University Hospital, Tuebingen, Germany and Constance Hospital, Constance, Germany), Thiago Lisboa (Joan XIII University Hospital, Tarragona, Catalonia and CIBER Enfermedades Respiratorias), (Antonio Macor, Amedeo di Savoia Hospital, Torino, Italy), Emilpaolo Manno (Maria Vittoria Hospital, Torino, Italy), R. Mañez (Bellvitge University Hospital, Barcelona, Catalonia), Brian Marsh (Mater Misericordiae University Hospital, Dublin, Ireland), Claude Martin (Nord University Hospital, Marseille, France), Ignacio Martin-Loeches (Mater Misericordiae University Hospital, Dublin, Ireland), Pavlos Myrianthefs (KAT Hospital, Athens, Greece), M. Nawynck (St Jan Hospital, Brugges, Belgium), Laurent Papazian (Sainte Marguerite University Hospital, Marseille, France), Christian Putensen (Bonn University Hospital, Bonn, Germany), Bernard Regnier (Claude Bernard University Hospital, Paris, France), Jordi Rello (Joan XIII University Hospital, Tarragona, Catalonia), Jordi Sole-Violan (Dr. Negrin University Hospital, Gran Canarias, Spain), Giuseppe Spina (Mauriziano Umberto I Hospital, Torino, Italy), Arzu Topeli (Hacettepe University Hospital, Ankara, Turkey), Hermann Wrigge (Bonn University Hospital, Bonn, Germany).

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Martin-Loeches, I., Lisboa, T., Rodriguez, A. et al. Combination antibiotic therapy with macrolides improves survival in intubated patients with community-acquired pneumonia. Intensive Care Med 36, 612–620 (2010). https://doi.org/10.1007/s00134-009-1730-y

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