Background: Immunocompromised patients are often excluded from pneumonia trials, guidelines, and stewardship interventions.The objective of this study was to evaluate whether empiric broad-spectrum antibiotic treatment impacts mortality and other clinical outcomes in moderately immunocompromised patients without risk factors for multidrug-resistant organisms hospitalized with community-acquired pneumonia.
Methods: This was a target trial emulation including moderately immunocompromised (asplenia, hematologic malignancies, solid organ malignancy receiving chemotherapy, kidney transplant >1 year prior, congenital/acquired immunodeficiency and receiving immunosuppressive medications) patients with pneumonia without risk factors for multidrug-resistant organisms at 69 hospitals in the Michigan Hospital Medicine Safety ConsortiumThis study compared the receipt of empiric broad-spectrum antibiotics against antibiotics targeting typical respiratory pathogens on hospital day 1 or 2.The primary outcome was mortality. Secondary outcomes included length of stay, transfer to the intensive care unit and 30-day readmission, emergency department visit, Clostridioides difficile infection and antibiotic-associated adverse events.
Results: Of 2706 moderately immunocompromised patients with pneumonia, 59% (N=1596) received empiric broad-spectrum antibiotics. MRSA and resistant gram-negative bacteria were rare (94/2706, 3.5%). After adjustment, empiric broad-spectrum antibiotic treatment was not associated with mortality, but was associated with readmission (adjusted hazard ratio [aHR], 1.32 [1.05-1.66]), transfer to ICU (aHR, 2.65 [1.32-5.30]) and longer hospitalization (adjusted rate ratio [aRR], 1.14 [1.10-1.19]).
Conclusions: Immunocompromised patients hospitalized with pneumonia often receive empiric broad-spectrum antibiotics despite low rates of multidrug-resistant organisms. Empiric broad-spectrum antibiotic use was not associated with mortality, but was associated with harm, including 30-day readmission, transfer to ICU and longer duration of hospitalization.
Keywords: Immunocompromised patients; antimicrobial stewardship; community-acquired pneumonia; empiric antibiotics.
© The Author(s) 2025. Published by Oxford University Press on behalf of Infectious Diseases Society of America. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.