Comparative efficacy of levosimendan and dobutamine in sepsis-related cardiac impairment: a meta-analysis

Sepsis-induced cardiac dysfunction significantly impacts patient outcomes, with inotropic support playing a crucial role in management. Levosimendan and dobutamine are commonly used, but their comparative efficacy remains debated. This meta-analysis evaluates the efficacy and safety of levosimendan versus dobutamine in sepsis-related cardiac impairment, focusing on mortality, intensive care unit (ICU) outcomes, and infection risks.

We systematically analyzed randomized controlled trials (RCTs) comparing levosimendan and dobutamine in septic patients with cardiac dysfunction. Primary outcomes included mortality and ICU length of stay, while secondary outcomes assessed pneumonia, peritonitis, and urinary tract infection (UTI) risks. Model selection for pooled odds ratios (OR) or mean differences (MD) with 95% confidence intervals (CI) was based on heterogeneity, employing random-effects models for substantial heterogeneity (I² > 50%) and fixed-effects models otherwise. Meta-analyses were performed using Rev-Man 5.4.

Prospero ID (CRD420261283881).

The meta-analysis included 9 RCTs (n = 289 patients) in total. For mortality, data were available from 8 RCTs (n = 239 patients), revealing no significant reduction with levosimendan compared to dobutamine (OR: 0.89, 95% CI: 0.52-1.54, P = 0.68; I²=0%). For ICU length of stay, 7 RCTs (n = 241 patients) were included, showing no significant difference (MD - 2.02 days, 95% CI - 6.44 to 2.39; P = 0.37; I²=83%). Regarding hospital-acquired infections, pneumonia was analyzed in 5 RCTs (n = 143 patients) (OR: 1.05, 95% CI: 0.48-2.29, P = 0.90; I²=0%), peritonitis in 3 RCTs (n = 98 patients) (OR 1.56, 95% CI 0.62-3.95; P = 0.35; I²=0%), and urinary tract infections in 3 RCTs (n = 91 patients) (OR: 0.70, 95% CI: 0.17-2.81, P = 0.61; I²=0%).

Current evidence indicates that levosimendan does not reduce mortality or ICU length of stay compared to dobutamine in sepsis-induced cardiac dysfunction, and infection risks are comparable. The high heterogeneity in ICU outcomes warrants cautious interpretation. These findings do not support the routine preferential use of levosimendan over dobutamine. Larger, well-designed trials are needed to identify specific patient subgroups that may benefit from levosimendan.