Guideline-concordant pneumonia therapy lowers cardiovascular death risk in older patients

Key takeaways:

• Cardiovascular death risk 1 year after pneumonia hospitalization went down by 47% with guideline-concordant antibiotic therapy.
• This therapy also showed a trend toward a reduced all-cause mortality risk.

Among older adults who survived a community-acquired pneumonia infection, the risk for cardiovascular mortality 1 year after hospitalization decreased with guideline-concordant antibiotic therapy, according to results published in CHEST.

“This study found that the use of guideline-concordant antibiotic therapy among older hospitalized community-acquired pneumonia (CAP) survivors is associated with a significant (47%) reduction in their risk of cardiovascular death at 1 year following their index CAP admission,” Vicente F. Corrales-Medina, MD, clinician investigator in the clinical epidemiology program at Ottawa Hospital Research Institute and assistant professor in the department of medicine at University of Ottawa, and Carl van Walraven, MD, FRCPC, senior scientist of the clinical epidemiology program at Ottawa Hospital Research Institute and professor in the department of medicine at University of Ottawa, wrote.

Described as “among the most importance advances made in the care of patients with this infection in the last 3 decades,” guidelines for CAP therapy recommend the combination of a beta-lactam and a macrolide or monotherapy with a respiratory fluoroquinolone for nonsevere cases, and the combination of a broad-spectrum beta-lactam with a macrolide or a fluoroquinolone for severe cases requiring ICU care, the authors wrote.

Using data from The Ottawa Hospital between 2004 and 2015, Corrales-Medina and van Walraven assessed 1,909 patients (mean age, 81.3 years; 49.7% men) aged 65 years or older who survived hospitalization for CAP to see if there is a relationship between guideline-concordant antibiotic treatment use and the risk for all-cause and cardiovascular death 1 year later.

Researchers evaluated this association through proportional hazards regression models adjusted for several variables: overall 1-year expected mortality risk, CAP severity and history of previous pneumonia admissions, myocardial infarction admissions, heart failure or cerebrovascular disease.

The study population had a high comorbidity burden with a mean Charlson score of 2.6 and a 42% predicted risk for death at 1 year.

Most patients (89.7%) received a guideline-concordant antibiotic therapy.

By the 1-year mark, 68.7% of patients (mean age, 80.9 years; 47.1% men) remained alive, whereas 31.3% (mean age, 82.3 years; 55.4% men) died.

Between the two sets of patients, the variables of those who died suggested poorer health, including a higher Charlson score (mean, 3.6 vs. 2.2), more ED visits in the year prior to hospitalization ( 2: 39.3% vs. 26.2%), more hospitalizations by ambulance (1: 25.8% vs. 16.5%; 2: 16.6% vs. 7.6%), home oxygen use (11.5% vs. 3.4%), nursing home living status (25.1% vs. 14.6%), previous admission for pneumonia (15.4% vs. 8.9%) and a heightened expected risk for death at 1 year (43.2% vs. 40.2%).

Researchers noted similar differences between patients who did and did not receive guideline-concordant antibiotic therapy.

Patients with a previous admission for pneumonia faced an increased risk for all-cause mortality (HR = 1.27; 95% CI, 1.02-1.59).

Despite not reaching statistical significance, researchers observed a trend toward a reduced risk for all-cause mortality when patients used guideline-concordant antibiotic therapy (HR = 0.82; 95% CI, 0.65-1.04).

In contrast, the risk for cardiovascular mortality 1 year after hospitalization was lowered by nearly 50% with guideline-concordant antibiotic therapy (HR = 0.53; 95% CI, 0.34-0.8), according to researchers.

Of the total cohort, 145 patients died due to a cardiovascular issue, and those with a history of certain conditions/diseases faced a greater risk for this outcome: history of cerebrovascular disease (HR = 2.75; 95% CI, 1.66-4.55), myocardial infarction (HR = 1.67; 95% CI, 1.06-2.63) or heart failure (HR = 1.41; 95% CI, 0.97-2.04).

Notably, antibiotic class (beta-lactam, fluoroquinolone, macrolide) did not have an influence on all-cause or cardiovascular mortality risk, according to researchers.

Corrales-Medina and van Walraven wrote that discovering that guideline-concordant antibiotic therapy lowers the risk for 1-year cardiovascular mortality has several implications.

“This finding provides further support for compliance with existing recommendations for CAP treatment from current clinical practice guidelines,” Corrales-Medina and van Walraven wrote. “This finding also suggests that interventions at the time of CAP hospitalization may affect the long-term cardiovascular risk of CAP survivors. Future research will have to elucidate the mechanisms of this association.”