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Open Access Highly Accessed Research

Initial use of one or two antibiotics for critically ill patients with community-acquired pneumonia: impact on survival and bacterial resistance

Christophe Adrie12*, Carole Schwebel3, Maïté Garrouste-Orgeas45, Lucile Vignoud5, Benjamin Planquette6, Elie Azoulay7, Hatem Kallel8, Michael Darmon9, Bertrand Souweine10, Anh-Tuan Dinh-Xuan11, Samir Jamali12, Jean-Ralph Zahar13, Jean-François Timsit35 and This article was written on behalf of the Outcomerea Study Group

Author Affiliations

1 Physiology Department, Paris University, Cochin Hospital 27, rue du Faubourg Saint-Jacques, Paris, France

2 Polyvalent ICU, Delafontaine Hospital, Saint Denis, France

3 Polyvalent ICU, University Grenoble 1, Albert Michallon Hospital, Grenoble, France

4 ICU, Saint Joseph Hospital, Paris, France

5 University Grenoble 1, Integrated Research Center U823, Grenoble, France

6 Medical Surgical ICU, André Mignot Hospital, Versailles-Le Chesnay, France

7 Medical ICU, Saint Louis Hospital, Paris, France

8 ICU, Cayenne General Hospital, Cayenne, France

9 Medical ICU, Saint-Etienne University Hospital, Saint-Etienne, France

10 ICU, Gabriel Montpied Hospital, Clermont-Ferrand, France

11 Physiology Department, Cochin Hospital, Paris, France

12 ICU, Dourdan Hospital, Dourdan, France

13 Microbiology Department, Necker Hospital, Paris, France

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Critical Care 2013, 17:R265  doi:10.1186/cc13095

Published: 7 November 2013

Abstract

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

This is 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 to 0.94; P = 0.02); this effect was strongest in patients with Streptococcus pneumonia CAP (sHR, 0.05; 95% CI, 0.005 to 0.46; p = 0.001) or septic shock (sHR: 0.62; 95% CI 0.38 to 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 (β-lactam) and either of the two dual-therapy groups (β-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.