Efficacy of cefotaxime versus double regimens in the management of severe community-acquired pneumoniae (cap) in ICU.

 

F; Paganin, D; Morau, E. Spilmann, J. Souk-aloun, J.L. Yvin, A. Seciuk, Y. Djardem, Th. Garnaud, F. Lilienthal*, B-A. Gaüzère.

Service de Réanimation, Médecine Interne, CHD Félix Guyon. Saint Denis-Réunion. FRANCE, *Collegeville, PA, USA

 

Introduction : CAP requiring admission in ICU are usualy linked with a high mortality rate (22 to 54%), particularly in patients undergoing mechanical ventilation (MV). Previous studies suggested that the causative agent identification does not influence the overall survival.

However, the knowledge of a particular local bacteriological epidemiology guides the appropriate empirical antibiotherapy (AB), pending the bactreriological identification whenever avaible. Invasive procedures, ie bronchoalveolar lavage, protected brush, have been proved usefull for the diagnosis of nosocomial pneumonia. Concensus conferences usually recommend the use of an AB combination in the management of severe CAP.

Aim : To assess that a single broad spectrum antibiotic is as effective as multiple regimens for the treatment of severe community-acquired pneumonia.

 

Methods

Hospital and ICU : The ICU is located in a non-teaching 530 beds hospital, with a referring area of 350,000 people. The unit is divided in two sub-unit of 8 beds each. Routine hemodynamic explorations are performed (echocardiography, Swan-Ganz cathter). A special care are provided to obtain a bacterial identification for patients with suspicion of pneumonia (community or nosocomial acquired).

Protocols : Epidemological profile was assessed through fiberbronchoscopy (FB) with bronchoalveolar lavage and/or protected brush. Empirical AB was started according to the direct examination (DE) and the physician’ experience. Monotherapy (cefotaxime 3 to 4 gr/day) was used whenever DE showed gram + cocci (likely pneumococcus) or gram - bacili (haemophilus or klebsiella). Double regimen (b lactam + macrolide or quinolone or aminoglycoside) was used in case of negative DE or FB not feasible.

 

Analysis of data

1- This study was conducted prospectively in term of epidemiological survey and for the outcome analysis.

2- The evaluation of the efficacy of the several antibiotics regimens was conducted retrospectively.

Parametrics square tests were used for the analysis.

 

Patients : 84 patients (54 +/-15 y) were admitted in our ICU from July 1994 to December 1996.

 

Results :  80 % required MV. Bacteriological identification was obtained in 80% (S. Pneumoniae: 41%, Klebsiella: 20%,Haemophilus: 5%, Miscellaneous: 17%). No identification in 14 cases (17 %). The mortality was significally different between S Pneumoniae and Klebsiella infections (p < 0.04). However, the difference does not reach stastitical significance, whenever using a multiple factor analysis test. The explanation is, that presence or absence of septic shock is the main prognosis factor associated with overall mortality.

Antibiotic therapy

Cefotaxime alone was administered in 19 cases (group 1). The dose ranged from 1 to 2 gr/T.I.D according to the body weight, in a 10 minutes IV perfusion. Multiple therapy was administered in 65 patients (group 2):

            Amoxicillin/Clavulanic acid + Gentamycin: 48%

            Cefotaxime + Gentamycin: 28%

            Amoxicillin/Clavulanic acid + fluoroquinolone: 9%

            Cefotaxime or Piperillin + fluoroquinolones: 10%

            Miscellaneous: 5%

The doses ranged for amox/clav from 1 to 2 Gr/T.I.D, gentamycin: 4 mg/kg (with a plasmatic dosage), quinolones: 200 mg /B.I.D (ofloxacine), 400 mg/B.I.D (pefloxacine)

The 2 groups were identical for demographics data, shock and acidosis, positive blood cultures and % of MV.

The overall mortality was 38 % : group 1: 33.3%, group 2: 38.5 %

Mortality rates were identical among patients with or without bacteriological identification.

Among survivors, apyrexia was obtained in a mean of 3.8 days:

            Group 1: 3.5      NS

            Group 2: 3.9      NS

 

Discussion

1- This study confirms that severe community acquired pneumoniae are strongly associated with high mortality rate in patients requiring mechanical ventilation.

2- More than bacterial etiology, the occurence of a septic shok is the main mortality factor,

3- An unexpected high rate of Klebsiella species is linked to a tremendous rate of alcohol consumption in this population in youg males patients.

4- None of the bacterial species were resistant to the usual antibiotic used which  confirmed the community origin of the patients.The high overall mortality is not related to AB failure but to the poor general status.

5- Single AB regimen using cefotaxime is therefore safe to cure severe CAP patients in ICU.

 

Conclusion : Monotherapy based on cefotaxime is safe in the management of severe CAP in ICU. However, the safe implementation of such a regimen requires a bacterial identification and a knowledge of the local epidemiology.