Outcomes of Macrolide Deescalation in Severe Community-acquired Pneumonia

Clin Ther. 2019 Dec;41(12):2540-2548. doi: 10.1016/j.clinthera.2019.10.005. Epub 2019 Oct 29.

Abstract

Purpose: Current data suggest potential benefits with β-lactam plus macrolide combination therapy for empiric treatment of intensive care unit (ICU) patients with severe community-acquired pneumonia (CAP). However, it is unclear whether deescalation to β-lactam monotherapy in the absence of positive results on diagnostic tests, such as the BioFire FilmArray Respiratory Panel 2 (BioFire polymerase chain reaction [PCR]), affects clinical outcomes. The purpose of this study was to compare outcomes between patients with negative BioFire PCR results deescalated to β-lactam monotherapy with those not deescalated.

Methods: This single-center, retrospective cohort study assessed the in-hospital mortality rates of critically ill adults with CAP treated for ≥48 h with combination β-lactam and azithromycin therapy. Additional end points included hospital length of stay (LOS), ICU LOS, duration of mechanical ventilatory support, 30-day readmission, and incidence of azithromycin-related adverse effects.

Findings: A total of 94 patients were included: 53 in the deescalation group and 41 in the nondeescalation group. No difference was observed with respect to in-hospital mortality (2.4% vs 11.3%, P = 0.312), although patients in the deescalated group experienced shorter ICU (1.9 vs 3.4 days, P = 0.029) and hospital LOS (6 vs 7 days, P = 0.025). No differences were found between groups with respect to additional secondary end points. Simple logistic regression confirmed that deescalation was not associated with hospital mortality (odds ratio = 0.17, 95% CI, 0.02-1.70).

Implications: In this study of ICU patients with severe CAP and a negative BioFire PCR result, deescalation from combination β-lactam and macrolide therapy to β-lactam monotherapy was not associated with increased in-hospital mortality but was associated with decreased hospital and ICU LOS. Larger prospective studies are warranted to verify these findings.

Keywords: antimicrobial stewardship; antimicrobial therapy; community-acquired pneumonia; intensive care unit.

MeSH terms

  • Anti-Bacterial Agents* / administration & dosage
  • Anti-Bacterial Agents* / adverse effects
  • Anti-Bacterial Agents* / therapeutic use
  • Community-Acquired Infections / drug therapy*
  • Community-Acquired Infections / mortality
  • Critical Illness
  • Humans
  • Inappropriate Prescribing* / prevention & control
  • Inappropriate Prescribing* / statistics & numerical data
  • Macrolides* / administration & dosage
  • Macrolides* / adverse effects
  • Macrolides* / therapeutic use
  • Pneumonia, Bacterial / drug therapy*
  • Pneumonia, Bacterial / mortality
  • Retrospective Studies

Substances

  • Anti-Bacterial Agents
  • Macrolides