Christophe Adrie, Carole Schwebel, Maïté Garrouste-Orgeas, Lucile Vignoud, Benjamin Planquette, Elie Azoulay, Hatem Kallel, Michael Darmon, Bertrand Souweine, Anh-Tuan Dinh-Xuan, Samir Jamali, Jean-Ralph Zahar, Jean-François Timsit Critical Care 2013, 17:R265 (7 November 2013)
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.
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