Pneumococal community-acquired pneumonia in the intensive care unit: Azithromycin remains protective despite macrolide resistance

• Published in: Respiratory medicine Vol. 177; p. 106307
• Main Authors: Shorr, Andrew F., Simmons, James, Hampton, Nicolas, Micek, Scott T., Kollef, Marin H.
• Format: Journal Article
• Language: English
• Published: England Elsevier Ltd 01.02.2021; Elsevier Limited
• Subjects: Antibiotics; Azithromycin; Blood; Chronic illnesses; Chronic obstructive pulmonary disease; Comorbidity; Disease; Hospitals; Intensive care; Intensive care unit; Mechanical ventilation; Mortality; Multivariate analysis; Pathogens; Patients; Pneumonia; Streptococcus infections; Variables; United States > US; Pneumonia; Mortality; Intensive care unit; Azithromycin
• DOI: 10.1016/j.rmed.2021.106307
• ISSN: 0954-6111; 1532-3064

Streptococcus pneumoniae (SP) remains the leading pathogen in community-acquired pneumonia (CAP). Despite the increasing prevalence of macrolide resistance in SP, guidelines recommend the use of macrolides as part of a combination regiment for intensive care unit (ICU) patients with CAP. We sought to describe if macrolide resistance effects outcomes in SP CAP in the ICU and if macrolides remain associated with a mortality advantage in an era of greater resistance. We identified all patients with SP CAP admitted to the ICU between January 2012 and December 2016, and hospital mortality represented the primary endpoint. We recorded markers of acute and chronic disease severity (eg, Charlson score, need for mechanical ventilation and/or vasopressors) along with infection-related variables including the presence of macrolide resistance. We compared subjects treated with azithromycin to those not given this agent. The cohort included 140 subjects (89.2% on mechanical ventilation, 14.3% crude mortality). Macrolide resistance occurred often (60.8%) and, in univariate analyses, was associated with higher mortality while azithromycin use appeared linked to fewer death. In multivariate analysis controlling for multiple confounders including macrolide resistance and the timeliness and appropriateness of antibiotic therapy, treatment with azithromycin resulted in fewer death (Adjusted odds ratio 0.27, 95% confidence interval: 0.09–0.85, p = 0.024). Macrolide resistance, however, was not independently related to mortality. Macrolide resistance appears frequently in SP ICU CAP. The addition of azithromycin to the antibiotic regimen in this scenario is significantly associated with a reduction in in-hospital mortality independent of multiple co-variates. •Macrolide resistance is common in Streptococcus pneumoniae causing severe community-acquired pneumonia.•Azithromycin treatment is associated with survival in S. pneumoniae community-acquired pneumonia in critically ill patients.•The benefit related to azithromycin is independent of multiple possible factors to include macrolide resistance.