Macrolide therapy is associated with lower mortality in community-acquired bacteraemic pneumonia

Arnold, Forest W.; Lopardo, Gustavo; Wiemken, Timothy; Kelley, Robert; Peyrani, Paula; Mattingly, William A.; Feldman, Charles; Gnoni, Martin; Silva, Rosemeri Maurici da; Ramirez, Julio A.

doi:10.1016/j.rmed.2018.05.020

Cited by 13 publications

(10 citation statements)

References 26 publications

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“…A recent study has shown better outcomes in patients who received macrolide therapy and presented with bacteremic pneumonia. 34 Moreover, the most common cause of bacteremic pneumonia was pneumococcus in 74% of patients, and although the authors did not look at CRP levels, patients with invasive pneumococcal CAP usually presented greater levels of CRP. 35 A recent meta-analysis that compared the combination of a b-lactam with a macrolide vs a b-lactam with a fluoroquinolone showed no significant differences in short-term mortality (adjusted risk ratio, 1.26; 95% CI, 0.95-1.67; I 2 , 43%) 36 ; and another metaanalysis showed that ceftriaxone combination therapy was similar in terms of treatment success compared with fluoroquinolone monotherapy in patients with CAP.…”

Section: Discussionmentioning

confidence: 98%

Effect of Combined β-Lactam/Macrolide Therapy on Mortality According to the Microbial Etiology and Inflammatory Status of Patients With Community-Acquired Pneumonia

Ceccato¹,

Cillóniz²,

Martín‐Loeches

et al. 2019

Chest

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BACKGROUND: Antibiotic combinations that include macrolides have shown lower mortality rates than b-lactams in monotherapy or combined with fluoroquinolones in patients with community-acquired pneumonia (CAP). However, this effect has not been studied according to the levels of C-reactive protein in CAP with identified microbial cause. In patients with CAP and known microbial cause we aimed to evaluate 30-day mortality of a b-lactam plus macrolide (BL þ M) compared with a fluoroquinolone alone or with a b-lactam (FQ AE BL). METHODS: We analyzed a prospective observational cohort of patients with CAP admitted to the Hospital Clinic of Barcelona between 1996 and 2016. We included only patients with known microbial cause. RESULTS: Of 1,715 patients (29%) with known etiology, a total of 932 patients (54%) received BL þ M. Despite lower crude mortality in the BL þ M group in the overall population (BL þ M, 5% vs FQ AE BL, 8%; P ¼ .015), after adjustment by a propensity score and baseline characteristics, the combination of BL þ M had a protective effect on mortality only in patients with high inflammatory response (C-reactive protein, > 15 mg/dL) and pneumococcal CAP (adjusted OR, 0.28; 95% CI, 0.09-0.93). No benefits on mortality were observed for the population without high inflammatory response and pneumococcal CAP or with other etiologies. CONCLUSIONS: The combination of a b-lactam with a macrolide was associated with decreased mortality in patients with pneumococcal CAP and in patients with high systemic inflammatory response. When both factors occurred together, BL þ M was protective for mortality in the multivariate analysis.

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Section: Discussionmentioning

confidence: 98%

Effect of Combined β-Lactam/Macrolide Therapy on Mortality According to the Microbial Etiology and Inflammatory Status of Patients With Community-Acquired Pneumonia

Ceccato¹,

Cillóniz²,

Martín‐Loeches

et al. 2019

Chest

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“…[ 38 , 39 ] The latter has been the rationale for including macrolides as part of the treatment regimen for SP infections even when resistance is demonstrated. [ 40 ] Additional investigations are warranted to verify our findings and to determine the optimal treatment approaches for SP infections. Developing new prevention strategies and treatment paradigms for SP infections is critical given the lack of mortality improvement with this infection over the past twenty years.…”

Section: Discussionmentioning

confidence: 79%

Characteristics and outcomes among a hospitalized patient cohort with Streptococcus pneumoniae infection

et al. 2020

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Infection due to Streptococcus pneumoniae (SP) requiring hospitalization is common. However, recent clinical studies describing patient characteristics and outcomes for SP infection in adults requiring hospitalization are lacking. Our goal was to evaluate patient characteristics, contemporary antibiotic resistance, and clinical outcomes among hospitalized adults with SP infections. A retrospective cohort study was conducted at Barnes-Jewish Hospital (1350 beds) in St. Louis, Missouri, USA for years 2012 through 2016. During the study period, 358 hospitalized adults, excluding those with meningitis, were identified with SP infection. Forty-four patients (12.3%) died within 30 days of the identification of their infection. Among these infections, 99 (27.7%) were assessed to be hospital-acquired and 259 (72.3%) were community-onset infections. The majority of infections involved the respiratory tract (88.5%). Azithromycin resistance was the most common antibiotic resistance at 51.4%, followed by enteral penicillin resistance (45.3%), trimethoprim-sulfamethoxazole (34.1%), second-generation cephalosporin (cefuroxime) (30.7%), and meropenem (22.6%). There were 70 isolates (19.6%) classified as multidrug resistant. Independent predictors of hospital mortality included increasing weight in 1-kilogram increments (adjusted odds ratio [AOR], 1.02; 95% CI, 1.01 – 1.02; P = .048), increasing Charlson Comorbidity Index scores (AOR, 1.31; 95% CI, 1.21 – 1.42; P = .001), and the presence of septic shock (AOR, 3.89; 95% CI, 2.31 – 6.57; P = .009). The median [interquartile range] hospital length of stay was 8.1 days [4.5 days, 16.8 days]. Hospitalized patients with infection attributed to SP have significant 30-day mortality and use of hospital resources. Antibiotic resistance is common among isolates associated with infection. Determinants of mortality are primarily severity of illness, underlying comorbidities and increasing patient weight. Efforts to improve the treatment and prevention of SP infections are needed.

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“…A recent study found lower in-hospital mortality in patients with bacteremic CAP who received a macrolide. 11 Although 95% of patients in both groups had adequate coverage for the identified pathogen, the lack of benefit of fluoroquinolones suggests that the macrolide benefit may be related to immunomodulatory activity rather than spectrum of activity. The emerging role for corticosteroids in PNA also indicates that immunomodulation may be beneficial.…”

Section: Discussionmentioning

confidence: 97%

Antibiotic Use and Respiratory Pathogens in Adults With Sickle Cell Disease and Acute Chest Syndrome

et al. 2019

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Background: Acute chest syndrome (ACS) is an acute complication of sickle cell disease (SCD). Historically, the most common pathogens were Chlamydophila pneumoniae, Mycoplasma pneumoniae, and respiratory syncytial virus. Pediatric patients receiving guideline-adherent therapy experienced fewer ACS-related and all-cause 30-day readmissions compared with those receiving nonadherent therapy. This has not been evaluated in adults. Objectives: The primary objectives were to characterize antibiotic use and pathogens. The secondary objective was to assess the occurrence of readmissions associated with guideline-adherent and clinically appropriate treatment compared with regimens that did not meet those criteria. Methods: A retrospective cohort analysis was conducted for adults with SCD hospitalized between August 1, 2014, and July 31, 2017, with pneumonia (PNA) or ACS. The study was approved by the institutional review board. Results: A total of 139 patients with 255 hospitalizations were reviewed. Among 41 respiratory cultures, 3 organisms were isolated: Cryptococcus neoformans, Pseudomonas aeruginosa, and budding yeast. Respiratory panels were collected on 121 admissions, with 17 positive for 1 virus; all were negative for Chlamydophila pneumoniae and M pneumoniae. There were significantly more ACS-/PNA-related 7-day readmissions from patients on guideline-adherent regimens compared with nonadherent regimens (3.7% vs 0%; P = 0.04). Conclusion and Relevance: These findings challenge existing knowledge regarding the most common pathogens in adults with SCD with ACS or PNA. Routine inclusion of a macrolide may not be necessary. Future studies focused on pathogen characterization with standardized assessment are necessary to determine appropriate empirical therapy in this population.

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Macrolide therapy is associated with lower mortality in community-acquired bacteraemic pneumonia

Abstract: In-hospital mortality, but not 30-day mortality, was significantly better in the macrolide group. Our data support the use of a macrolide in hospitalized patients with CAP and bacteraemia.

Cited by 13 publications

References 26 publications

Effect of Combined β-Lactam/Macrolide Therapy on Mortality According to the Microbial Etiology and Inflammatory Status of Patients With Community-Acquired Pneumonia

Effect of Combined β-Lactam/Macrolide Therapy on Mortality According to the Microbial Etiology and Inflammatory Status of Patients With Community-Acquired Pneumonia

Characteristics and outcomes among a hospitalized patient cohort with Streptococcus pneumoniae infection

Antibiotic Use and Respiratory Pathogens in Adults With Sickle Cell Disease and Acute Chest Syndrome

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