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Mortality in ICU patients with bacterial community-acquired pneumonia: when antibiotics are not enough

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Abstract

Background

It remains uncertain why immunocompetent patients with bacterial community-acquired pneumonia (CAP) die, in spite of adequate antibiotics.

Methods

This is a secondary analysis of the CAPUCI database which was a prospective observational multicentre study. Two hundred and twelve immunocompetent patients admitted to 33 Spanish ICUs for CAP were analyzed. Comparisons were made for lifestyle risk factors, comorbidities and severity of illness. ICU mortality was the principal outcome variable.

Results

Bacteremic CAP (43.3 vs. 21.1%) and empyema (11.5 vs. 2.2%) were more frequent (P < 0.05) in patients with Streptococcus pneumoniae CAP. Higher rates of adequate empiric therapy (95.8 vs. 75.5%, P < 0.05) were observed in patients with S. pneumoniae CAP. Patients with non-pneumococcal CAP experienced more shock (66.7 vs. 50.8%, P < 0.05), and need for mechanical ventilation (83.3 vs. 61.5%, P < 0.05). ICU mortality was 20.7 and 28% [OR 1.49(0.74–2.98)] among immunocompetent patients with S. pneumoniae (n = 122) and non-pneumococci (n = 90), in spite of initial adequate antibiotic. Multivariable regression analysis in these 184 immunocompetent patients with adequate empirical antibiotic treatment identified the following variables as independently associated with mortality: shock (HR 13.03); acute renal failure (HR 4.79), and APACHE II score higher than 24 (HR 2.22).

Conclusions

Mortality remains unacceptably high in immunocompetent patients admitted to the ICU with bacterial pneumonia, despite adequate initial antibiotics and comorbidities management. Patients with shock, acute renal failure and APACHE II score higher than 24 should be considered for inclusion in trials of adjunctive therapy in order to improve CAP survival.

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Acknowledgments

We are indebted to Montserrat Olona for statistical advice and critical review of the manuscript. This study has been supported in part by Health Research Founds (FISS PI 04/1500 and FISS 05/2401), Generalitat de Catalunya Grant (SGR 05/920), and CIBER Enfermedades Respiratorias (CIBERES) by Carlos III Health Institute Grant.

Conflict of interest statement

Dr Rello serves as consultant and in the speakers Bureau for Novartis. The remaining authors declare that they have no competing interest.

Author information

Authors and Affiliations

  1. Critical Care Department, Pere Virgili Health Institut and CIBER Enfermedades Respiratorias (CIBERES), Joan XXIII University Hospital, Mallafré Guasch 4, 43007, Tarragona, Spain

    Alejandro Rodriguez, Thiago Lisboa & Jordi Rello

  2. Department of General Internal Medicine and Infectious Diseases, Ghent University Hospital, Ghent, Belgium

    Stijn Blot

  3. Faculty of Healthcare, Ghent University College, Ghent, Belgium

    Stijn Blot

  4. Faculty of Medicine and Health Science, Ghent University, Ghent, Belgium

    Stijn Blot

  5. Intensive Care Unit, Hospital St James, Dublin, Ireland

    Ignacio Martin-Loeches

  6. Critical Care Department, Dr. Negrin Hospital, Gran Canary, Spain

    Jorge Solé-Violan

  7. Critical Care Department, Parc Taulí Hospital, Sabadell, Spain

    Diego De Mendoza

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  1. Alejandro Rodriguez
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  2. Thiago Lisboa
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  5. Jorge Solé-Violan
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  6. Diego De Mendoza
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  7. Jordi Rello
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Consortia

Community-Acquired Pneumonia Intensive Care Units (CAPUCI) Study Investigators

Corresponding author

Correspondence to Jordi Rello.

Additional information

This article is discussed in the editorial available at: doi:10.1007/s00134-008-1366-3.

Electronic supplementary material

Below is the link to the electronic supplementary material.

134_2008_1363_MOESM1_ESM.doc

Table A Diagnostic examinations performed in 212 immunocompetent patients with bacterial community-acquired pneumonia distributed according to the causative aetiology. (supplementary electronic material) (DOC 47 kb)

The CAPUCI study investigators

The CAPUCI study investigators

J. Solé-Violan (Dr. Negrin Hospital, Gran Canaria), J. Blanquer (Clinic Hospital, Valencia), J. Jiménez (Virgen Del Rocio Hospital, Seville), V. de la Torre (Virgen De La Victoria Hospital, Malaga), J. M. Sirvent (Josep Trueta Hospital, Girona), M. Bodí (Joan XXIII Hospital, Tarragona), J. Almirall (Mataró Hospital, Mataró, Barcelona), A. Doblas (Juan Ramon imenez Hospital, Huelva), J. R. Badía (Clinic Hospital, Barcelona), F. García (General Hospital, Albacete), A. Mendia (Nuestra Señora de Aranzazu Hospital, San Sebastian), R. Jordá (Son Dureta Hospital, Palma de Mallorca), F. Bobillo (Clinico Hospital, Valladolid), J. Vallés (Hospital Parc Tauli, Sabadell, Barcelona), M. J. Broch (Sagunto Hospital, Valencia), N. Carrasco (Princesa Hospital, Madrid), M. A. Herranz (Rio Hortega Hospital, Valladolid), F. Alvarez Lerma (Del Mar Hospital, Barcelona), E. Messales (Trias i Pujol Hospital, Badalona, Barcelona), B. Alvarez (General Hospital, Alicante), J. C. Robles (Reina Sofia Hospital, Córdoba), E. Maravi (Virgen Del Camino Hospital, Pamplona), F. Barcenilla (Arnau de Vilanova Hospital, Lleida), M. A. Blasco (Peset Aleixandre Hospital, Valencia), G. Masdeu (Verge de la Cinta Hospital, Tortosa, Tarragona), M. J. López Pueyo (General Yague Hospital, Burgos), A. Margarit (Virgen Meritxell Hospital, Andorra), J. Fierro (Poniente Hospital, Almeria), F. Renedo (Leon Hospital, Leon), A. Lores (Bellvitge Hospital, Barcelona), R. Alonso (General de Asturias Hospital, Oviedo), M. J. Huertos (Puerto Real Hospital, Cadiz), and M. J. López (General Hospital, Segovia).

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Rodriguez, A., Lisboa, T., Blot, S. et al. Mortality in ICU patients with bacterial community-acquired pneumonia: when antibiotics are not enough. Intensive Care Med 35, 430–438 (2009). https://doi.org/10.1007/s00134-008-1363-6

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  • DOI: https://doi.org/10.1007/s00134-008-1363-6

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