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Physicians urged to consider alternative treatments for at-risk pneumonia patients
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Despite receiving appropriate initial antibiotic therapy, pneumonia patients with two or more risk factors had greater 30-day mortality than those with fewer risk factors, suggesting the need for adjunctive therapy other than antibiotics for those at greater risk, according to research published in The Lancet Infectious Diseases.
“Over several decades, many potent antibiotics have been developed that are effective against many bacterial pathogens. However, pneumonia remains one of the leading causes of death worldwide,” Yuichiro Shindo, MD, PhD, assistant professor in the department of respiratory medicine, Nagoya University Graduate School of Medicine, Japan, and colleagues wrote. “Many patients have benefited from the newly developed antibiotics. However, many patients also develop adverse outcomes, even if they receive appropriate initial antibiotics.”
As a result, Shindo and colleagues investigated the risk factors for 30-day mortality in patients who received appropriate initial antibiotic treatment and identified patients who would benefit from adjunctive therapy for improved outcomes. The researchers conducted a prospective, observational study of pneumonia patients from 10 health care institutions from March 15 to Dec. 22, 2010. The final cohort for the primary analysis included 579 pneumonia patients aged 20 years and older who were given appropriate initial antibiotic treatment while hospitalized.
Forty-two percent of patients who received appropriate antibiotic therapy were aged 80 years or older, and they comprised 62% of those who did not survive after 30 days (P = .001). Common comorbidities for those who received appropriate treatment who did not survive included chronic lung diseases (36%) and central nervous system disorders (36%).
Independent risk factors for 30-day mortality of pneumonia patients who received appropriate initial antibiotic treatment were nonambulatory status (adjusted OR = 3.34; 95% CI, 1.84-6.05); albumin of less than 30 mg/L (aOR = 3.39; 95% CI, 1.83-6.28); respiration rate of 30 or more breaths per minute (aOR = 2.33; 95% CI, 1.28-4.24); pH of less than 7.35 (aOR = 3.13; 95% CI, 1.52-6.42); and blood urea nitrogen level of 7.14 mmol/L or greater (aOR = 2.2; 95% CI, 1.13-4.3). Interaction between these risk factors was not significant, the researchers said.
When patients had one or no risk factors, 30-day mortality was 1%. However, it jumped to 17% for those with two risk factors, 22% for those with three risk factors, and 44% for those with at least four risk factors, according to Shindo and colleagues.
The main study group also was compared with 168 patients who did not receive appropriate initial antibiotic treatment. At 30 days, mortality was 11% in the group administered appropriate initial antibiotic treatment vs. 17% for the group that received inappropriate treatment (P = .018). Patients who were administered appropriate initial antibiotic treatment had an in-hospital mortality rate of 14%, compared with 21% for those who received inappropriate treatment (P = .023), according to the researchers.
“For patients with two or more risk factors, appropriate selection of initial antibiotics is needed, and adjunctive therapy other than antibiotic treatment might have an important role in improving the outcomes,” they wrote. – by David Jwanier
Disclosure: Shindo reports receiving travel support from the Naito Foundation that was related to the study, as well as travel, accommodations or meeting expenses from Pfizer for work outside of the study. He also reports receiving payment for lectures from multiple pharmaceutical companies. Please see the full study for a list of all other authors’ relevant financial disclosures.
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