CAP deaths in ICU cut by early antibiotics, combined antibiotic therapy

In the last decade, ICU mortality due to severe pneumococcal pneumonia has significantly decreased. Improved survival is associated with earlier antibiotic prescribing and an increased use of combined antibiotic therapy, according to a study reported online in Chest.

Deaths related to severe community-acquired pneumonia (CAP) fell from 32.5% in 2000-2002 to 17.5%  during 2008-2013, according to study author Simone Gattarello, MD, of Vall d'Hebron University Hospital in Barcelona, and colleagues.

CAPUCI I and II

The case-controlled study consisted of two observational prospectively recorded cohorts in Europe. CAPUCI I and II (Community-Acquired Pneumonia en la Unidad de Cuidados Intensivos) were two European, observational, prospective, multicenter studies performed in patients admitted to the ICU for CAP. The CAPUCI I study recorded data from 33 hospitals from 2000 to 2002. The CAPUCI II study was a follow-up project from 2008 to 2013 in 29 European ICUs. Eighty patients from CAPUCI II database (case group) were matched with 80 from CAPUCI I (control group). Matching variables were the following: presence of shock at ICU admission, need for mechanical ventilation, COPD, immunosuppression, and age. Mortality and the characteristics of antibiotic treatment were analyzed.

Findings

“The main findings from the present study are a 15% decrease in ICU mortality due to severe community-acquired pneumonia caused by Streptococcus pneumoniae in the last decade,” said Gattarello.

“Moreover, several changes in antibiotic prescription practices were detected and an association between improved survival and both earlier antibiotic administration and increased combined antibiotic therapy were identified. In summary, in severe pneumococcal pneumonia combined antibiotic therapy and early antibiotic administration are associated with lower mortality.”

Gattarello and colleagues said that significant predictors of lower ICU mortality risk included:

• Beginning antibiotics within 3 hours of admission to the emergency department (OR 0.36, 95% CI 0.15–0.87)

• Combined antibiotic therapy (OR 0.19 vs monotherapy, 95% CI 0.07–0.51)

During the time period of these studies, the authors noted minimal change in worldwide mortality from lower respiratory infections and an increase in infectious disease overall. Changes in ICU practice were substantial, according to the outcomes documented during these two study periods.

Some numbers

Only 27.5% of the 80 patients with severe Streptococcus pneumoniae CAP in 33 European ICUs in the CAPUCI I prospective cohort study received the first dose of antibiotic within 3 hours of admission.

In the CAPUCI II follow-up, 70% of the 80 matched patients had taken the first dose of antibiotic within 3 hours of admission (P<0.01). In addition, combined antibiotic therapy climbed from 66.2% to 87.5% between the two time periods (2000-2002 and 2008-2013), respectively (P<0.01).

Also, in the case group, broader spectrum antibiotic combinations were used more often. Approximately 80% of patients in the CAPUCI II follow-up cohort received a combination of cephalosporin plus a macrolide or fluoroquinolone, compared with about half of those in the earlier cohort.

Almost 48% in the more recent study had received a combination of cephalosporin with a macrolide compared to only 33.8% in the earlier cohort (P=0.11).

The overall reduction in ICU mortality risk in the more recent period was statistically significant (OR 0.82, 95% CI 0.68-0.98).

Improved survival in all

“Previous studies published on the same issue only included patients with shock or under mechanical ventilation while our data show improved survival in all patients, both in the general population and in patients with shock or under mechanical ventilation, suggesting that the benefit of combined therapy is not limited to patients with shock,” said Gattarello. 

“This observation is not only of academic interest: in view of these results all patients with severe pneumococcal community-acquired pneumonia should receive early treatment and combined antibiotic therapy. Intensivists, specialists in emergency-medicine, or infectious disease specialist should consider the present article conclusions when starting a new antibiotic treatment; likewise, antibiotic-policies responsible and hospital decision-makers should consider our findings during the [creation] of protocols of management and treatment of patients with severe pneumonia.”

Due to the high mortality in its most severe presentations and the elevated incidence, CAP is a major health issue that is associated with high costs for the patient and for society.

“For this reason, every study realized to improve knowledge about this pathology helps to improve health of society and decrease healthcare costs,” Gattarello said.