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Amoxicillin/Clavulanate versus 3rd generation Cephalosporins for community-acquired pneumococcal pneumonia : is it an arbitrary choice?
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Introdução: As guidelines europeias recomendam a ceftriaxona ou amoxicilina/ácido clavulânico (AAC) como antibioterapia de primeira linha igualmente eficaz para a pneumonia adquirida na comunidade (PAC). Este estudo visa identificar características clínicas dos pacientes que podem influenciar a escolha do beta-lactâmico para a PAC e o respetivo prognóstico. Métodos: Foi realizado uma sub-análise de uma coorte retrospetiva multicêntrica de doentes com PAC pneumocócica. As características clínicas na admissão foram comparadas entre grupos de acordo com a sua antibioterapia empírica inicial. A mortalidade e os dias de hospitalização foram comparados entre grupos, ajustando-se à gravidade, à idade e admissão na unidade de cuidados intensivos (UCI). O software STATA v15.0 foi utilizado para análise estatística. Resultados: Incluímos 744 pacientes. 40,6% receberam ceftriaxona, 18,0% AAC, 8,3% quinolonas e 33,1% outros antibióticos. Os doentes que receberam ceftriaxona tiveram maior probabilidade de estarem sépticos e serem VIH positivos. Os pacientes que receberam ceftriaxona foram mais propensos a ter sépsis (odds ratio de 7,13, p < 0,001), menos propensos de apresentarem hiponatremia e internamento hospitalar por motivos cardiovasculares. Os doentes que receberam quinolonas, tinham maior tendência para receberem mais corticóides e tinham menos probabilidades de serem admitidos na UCI. A idade, pneumonia multilobar ou derrame pleural não influenciaram na escolha empírica dos antibióticos. Ao realizar a análise multivariada ajustada para sépsis, hiponatremia, bacteriemia e idade, não se verificou diferença na mortalidade entre os doentes que receberam um ou outro antibiótico. Como esperado, a sépsis [OR: 1.8 (1.2-2.6), p=0.003], a bacteriemia [OR: 2.1 (1.4-3.0), p< 0.001] e a idade [OR:1.04 (1.02-1.05), p< 0.001] foram fatores de risco significativos para a mortalidade. Conclusão: A escolha entre a antibioterapia empírica para a PAC não parece ser aleatória, apesar dos outcomes entre antibióticos de primeira linha serem idênticos. Estes dados podem ajudar a desenhar estratégias educativas sobre a administração de antibióticos.
Introduction: European guidelines recommend ceftriaxone or amoxicillin/clavulanate (AAC) as equally effective first-line antibiotic therapy for community-acquired pneumonia (CAP). This study aims to identify factors, including patients' clinical characteristics, that may influence the choice of beta-lactam empirical therapy for CAP and to relate this with patients' prognosis. Methods: This is a sub-analysis of a retrospective multicentric cohort study of pneumococcal CAP. Clinical characteristics at admission were compared according to their initial empirical antibiotic therapy: ceftriaxone, AAC, quinolones or other. Mortality and days of hospitalization were compared between groups, adjusting for severity, age, and ICU admission. STATA v15.0 software was used for statistical analysis. Results: We included 744 patients. 40.6% received ceftriaxone, 18.0% received AAC, 8.3% received quinolones and 33.1% other therapy. Patients that received ceftriaxone were more likely to be septic and HIV positive. Patients receiving ceftriaxone in CAP were more likely to have sepsis (odds ratio of 7.13, p< 0.001), and less likely to have hyponatremia (OR 0.44, P < 0.001) or have hospital admission due to cardiovascular reasons (OR 0.31, p< 0.001). Patients receiving quinolones tended to receive more corticoids (37.3% vs 33.1% vs 43.6% vs 26.3%, p<0.04) and were less likely to be admitted to the ICU (22.4% vs 23.2% vs 4.8% vs 13.0%, p<0.001). Age, multilobar pneumonia or pleural effusion did not influence empirical antibiotic choice. After adjusting for sepsis, hyponatremia, bacteriemia, and age, there was no difference in the mortality between patients receiving either antibiotic [OR: 1.2 (0.62- 2.3), p= 0.58]. As expected, sepsis [OR: 1.8 (1.2-2.6), p=0.003], bacteraemia [OR: 2.1 (1.4- 3.0), p< 0.001] and age [OR:1.04 (1.02-1.05), p< 0.001], were statistically associated with death. Conclusion: The choice between empirical therapy for CAP does not appear to be random despite comparable outcome effects between first-line antibiotics. This data may inform educational strategies on antibiotic stewardship.
Introduction: European guidelines recommend ceftriaxone or amoxicillin/clavulanate (AAC) as equally effective first-line antibiotic therapy for community-acquired pneumonia (CAP). This study aims to identify factors, including patients' clinical characteristics, that may influence the choice of beta-lactam empirical therapy for CAP and to relate this with patients' prognosis. Methods: This is a sub-analysis of a retrospective multicentric cohort study of pneumococcal CAP. Clinical characteristics at admission were compared according to their initial empirical antibiotic therapy: ceftriaxone, AAC, quinolones or other. Mortality and days of hospitalization were compared between groups, adjusting for severity, age, and ICU admission. STATA v15.0 software was used for statistical analysis. Results: We included 744 patients. 40.6% received ceftriaxone, 18.0% received AAC, 8.3% received quinolones and 33.1% other therapy. Patients that received ceftriaxone were more likely to be septic and HIV positive. Patients receiving ceftriaxone in CAP were more likely to have sepsis (odds ratio of 7.13, p< 0.001), and less likely to have hyponatremia (OR 0.44, P < 0.001) or have hospital admission due to cardiovascular reasons (OR 0.31, p< 0.001). Patients receiving quinolones tended to receive more corticoids (37.3% vs 33.1% vs 43.6% vs 26.3%, p<0.04) and were less likely to be admitted to the ICU (22.4% vs 23.2% vs 4.8% vs 13.0%, p<0.001). Age, multilobar pneumonia or pleural effusion did not influence empirical antibiotic choice. After adjusting for sepsis, hyponatremia, bacteriemia, and age, there was no difference in the mortality between patients receiving either antibiotic [OR: 1.2 (0.62- 2.3), p= 0.58]. As expected, sepsis [OR: 1.8 (1.2-2.6), p=0.003], bacteraemia [OR: 2.1 (1.4- 3.0), p< 0.001] and age [OR:1.04 (1.02-1.05), p< 0.001], were statistically associated with death. Conclusion: The choice between empirical therapy for CAP does not appear to be random despite comparable outcome effects between first-line antibiotics. This data may inform educational strategies on antibiotic stewardship.
Descrição
Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2023
Palavras-chave
Pneumonia adquirida na comunidade (PAC) Antibioterapia empírica Betalactâmico Ceftriaxona Amoxicilina Ácido clavulânico