Pneumococal community-acquired pneumonia in the intensive care unit: Azithromycin remains protective despite
Andrew F Shorr1, James Simmons2, Nicolas Hampton3
1Pulmonary & Critical Care Medicine, Washington Hospital Center, Washington, DC, USA.
Background:
Streptococcus pneumoniae (SP) remains the leading pathogen in community-acquired pneumonia (CAP). Despite the increasing prevalence of macrolide resistance in SP, guidelines recommend the use of macrolides as part of a combination regiment for intensive care unit (ICU) patients with CAP. We sought to describe if macrolide resistance effects outcomes in SP CAP in the ICU and if macrolides remain associated with a mortality advantage in an era of greater resistance.
Methods:
We identified all patients with SP CAP admitted to the ICU between January 2012 and December 2016, and hospital mortality represented the primary endpoint. We recorded markers of acute and chronic disease severity (eg, Charlson score, need for mechanical ventilation and/or vasopressors) along with infection-related variables including the presence of macrolide resistance. We compared subjects treated with azithromycin to those not given this agent.
Results:
The cohort included 140 subjects (89.2% on mechanical ventilation, 14.3% crude mortality). Macrolide resistance occurred often (60.8%) and, in univariate analyses, was associated with higher mortality while azithromycin use appeared linked to fewer death. In multivariate analysis controlling for multiple confounders including macrolide resistance and the timeliness and appropriateness of antibiotic therapy, treatment with azithromycin resulted in fewer death (Adjusted odds ratio 0.27, 95% confidence interval: 0.09-0.85, p = 0.024). Macrolide resistance, however, was not independently related to mortality.
Conclusions:
Macrolide resistance appears frequently in SP ICU CAP. The addition of azithromycin to the antibiotic regimen in this scenario is significantly associated with a reduction in in-hospital mortality independent of multiple co-variates.
Insights
Macrolide resistance is common in Streptococcus pneumoniae pneumonia in the ICU. Azithromycin use, however, significantly reduces mortality in these patients, even with resistance.
Area of Science:
- Infectious Diseases
- Critical Care Medicine
- Pharmacology
Background:
- Streptococcus pneumoniae (SP) is a primary cause of community-acquired pneumonia (CAP).
- Macrolide resistance in SP is increasing, yet macrolides are recommended for intensive care unit (ICU) CAP treatment.
- The impact of macrolide resistance on SP CAP outcomes in the ICU requires investigation.
Purpose of the Study:
- To determine if macrolide resistance affects outcomes in SP CAP patients in the ICU.
- To assess if macrolides offer a mortality advantage in the context of rising resistance.
- To evaluate the association between azithromycin use and mortality in SP CAP.
Main Methods:
- Retrospective analysis of 140 SP CAP patients admitted to the ICU (2012-2016).
- Primary endpoint: hospital mortality.
- Variables included disease severity, mechanical ventilation, vasopressor use, and macrolide resistance; azithromycin use was compared.
Main Results:
- Macrolide resistance was prevalent (60.8%).
- Univariate analysis showed resistance linked to higher mortality, while azithromycin use correlated with lower mortality.
- Multivariate analysis confirmed azithromycin use reduced mortality (aOR 0.27, p=0.024), independent of resistance and other factors.
Conclusions:
- Macrolide resistance is frequent in Streptococcus pneumoniae ICU CAP.
- Azithromycin addition to antibiotic regimens is independently associated with reduced in-hospital mortality in this patient group.
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