Divisions of Infectious Diseases, Department of Medicine, Queen's University, Kingston, ON, Canada.
General Internal Medicine, Department of Medicine, Queen's University, Kingston, ON, Canada.
Chest. 2024 Jan;165(1):68-78. doi: 10.1016/j.chest.2023.08.008. Epub 2023 Aug 11.
There are several antibiotic regimens to treat community-acquired pneumonia (CAP).
In patients hospitalized to a non-ICU ward setting with CAP, is there a difference between first-line and alternative antibiotic regimens (β-lactam plus macrolide [BL+M], β-lactam [BL] alone, respiratory fluoroquinolone [FQ], or β-lactam plus doxycycline [BL+D]) in terms of in-hospital mortality?
This retrospective cohort study included consecutive patients admitted with CAP at 19 Canadian hospitals from 2015 to 2021. Taking a target trial approach, patients were categorized into the four antibiotic groups based on the initial antibiotic treatment within 48 h of admission. Patients with severe CAP requiring ICU admission in the first 48 h were excluded. The primary outcome was all-cause in-hospital mortality. Secondary outcome included time to being discharged alive. Propensity score and overlap weighting were used to balance covariates.
Of 23,512 patients, 9,340 patients (39.7%) received BL+M, 9,146 (38.9%) received BL, 4,510 (19.2%) received FQ, and 516 (2.2%) received BL+D. The number of in-hospital deaths was 703 (7.5%) for the BL+M group, 888 (9.7%) for the BL group, 302 (6.7%) for the FQ group, and 31 (6.0%) for the BL+D group. The adjusted risk difference for in-hospital mortality when compared with BL+M was 1.5% (95% CI, -0.3% to 3.3%) for BL, -0.9% (95% CI, -2.9% to 1.1%) for FQ, and -1.9% (95% CI, -4.8% to 0.9%) for BL+D. Compared with BL+M, the subdistribution hazard ratio for being discharged alive was 0.90 (95% CI, 0.84-0.96) for BL, 1.07 (95% CI, 0.99-1.16) for FQ, and 1.04 (95% CI, 0.93-1.17) for BL+D.
BL+M, FQ, and BL+D had similar outcomes and can be considered effective regimens for nonsevere CAP. Compared with BL+M, BL was associated with longer time to discharge and the CI for mortality cannot exclude a small but clinically important increase in risk.
有几种抗生素方案可用于治疗社区获得性肺炎（CAP）。
在因 CAP 住院至非 ICU 病房的患者中，一线和替代抗生素方案（β-内酰胺加大环内酯类 [BL+M]、BL 单药治疗、呼吸氟喹诺酮类 [FQ]或 BL 加多西环素 [BL+D]）在院内死亡率方面是否存在差异？
本回顾性队列研究纳入了 2015 年至 2021 年期间在加拿大 19 家医院因 CAP 入院的连续患者。采用目标试验方法，根据入院后 48 小时内的初始抗生素治疗，将患者分为四组抗生素。排除在 48 小时内需要入住 ICU 的重症 CAP 患者。主要结局为全因院内死亡率。次要结局包括存活出院时间。采用倾向评分和重叠加权来平衡协变量。
在 23512 名患者中，9340 名（39.7%）患者接受 BL+M，9146 名（38.9%）患者接受 BL，4510 名（19.2%）患者接受 FQ，516 名（2.2%）患者接受 BL+D。BL+M 组院内死亡 703 例（7.5%），BL 组 888 例（9.7%），FQ 组 302 例（6.7%），BL+D 组 31 例（6.0%）。与 BL+M 相比，BL 的院内死亡率调整风险差异为 1.5%（95%CI，-0.3%至 3.3%），FQ 为-0.9%（95%CI，-2.9%至 1.1%），BL+D 为-1.9%（95%CI，-4.8%至 0.9%）。与 BL+M 相比，存活出院的亚分布风险比为 0.90（95%CI，0.84-0.96），BL 为 1.07（95%CI，0.99-1.16），FQ 为 1.04（95%CI，0.93-1.17），BL+D 为 1.04（95%CI，0.93-1.17）。
BL+M、FQ 和 BL+D 的结果相似，可被视为非重症 CAP 的有效治疗方案。与 BL+M 相比，BL 与出院时间延长相关，死亡率的 CI 不能排除风险略有增加但具有临床意义。
