Empirical use of fluoroquinolones improves the survival of critically ill patients with tuberculosis mimicking severe pneumonia

Abstract

IntroductionEmpirical use of fluoroquinolones may delay the initiation of appropriate therapy for tuberculosis (TB). This study aimed to evaluate the impact of empirical fluoroquinolone use on the survival of patients with pulmonary TB that mimicked severe community-acquired pneumonia (CAP) requiring intensive care.MethodsPatients aged >18 years with culture-confirmed pulmonary TB who presented as severe CAP and were admitted to the ICU were divided into fluoroquinolone (FQ) and nonfluoroquinolone (non-FQ) groups based on the type of empirical antibiotics used. Those patients with previous anti-TB treatment or those who died within 3 days of hospitalization were excluded. The primary end point was 100-day survival.ResultsOf the 77 patients identified, 43 (56%) were in the FQ group and 34 (44%) were in the non-FQ group. The two groups had no statistically significant difference in co-morbidities (95% vs. 97%, P > 0.99) and Acute Physiology and Chronic Health Evaluation (APACHE) II scores (21.2 ± 7.1 vs. 22.5 ± 7.5, P = 0.46) on ICU admission. Overall, 91% and 82% of patients in the FQ and non-FQ groups, respectively, had sputum examinations for TB within 1 week of admission (P = 0.46), and results were positive in 7% and 15% (P = 0.47), respectively. For both groups, 29% received appropriate anti-TB therapy within 2 weeks after ICU admission. The 100-day mortality rate was 40% and 68% for the FQ and non-FQ groups, respectively (P = 0.02). By Cox regression analysis, APACHE score <20, no bacteremia during the ICU stay, and empirical fluoroquinolone use were independently associated with survival.ConclusionEmpirical use of fluoroquinolones may improve the survival of ICU patients admitted for pulmonary TB mimicking severe CAP.

Impact of Fluoroquinolone Exposure Prior to Tuberculosis Diagnosis on Clinical Outcomes in Immunocompromised Patients

“…There are several reports of the impact of FQ exposure prior to TB diagnosis on various clinical outcomes in patients with TB (15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27). However, to our knowledge, this is the first study evaluating the impact of FQ use prior to TB diagnosis on clinical outcomes in immunocompromised patients with TB.…”

“…However, a recent study in Taiwan demonstrated that empirical use of FQ improved the survival rate of critically ill patients with TB that mimicked severe pneumonia, without causing treatment delay and FQ resistance (27). In that study, significantly more patients in the non-FQ group (27%) than in the FQ group (9%) died before anti-TB therapy was started.…”

“…Such a broad-spectrum antimicrobial activity of FQs has raised concerns that FQ exposure for any reason prior to TB diagnosis may be associated with adverse outcomes, such as a delay in anti-TB treatment (15)(16)(17), the emergence of FQ resistance (18)(19)(20)(21), and increased mortality (22,23). However, conflicting results have been obtained in several other studies (24)(25)(26)(27), and it is theoretically possible that FQ use until definitive anti-TB treatment is given might prevent clinical deterioration in missed TB patients. We therefore evaluated the association of FQ use prior to TB diagnosis with clinical outcomes in immunocompromised patients with TB, in whom TB is quite often missed.…”

The critically ill patient with tuberculosis in intensive care: Clinical presentations, management and infection control

“…21 Other documented risk factors for mortality include nosocomial pneumonia, multi-organ failure, TB destroyed lung, an APACHE II score >20 and duration of symptoms >4 weeks. 11,22,23…”

Limiting consumption in tuberculosis: current concepts in anti-tuberculosis treatment in the critically ill patient

“…rifampicin+moxifloxacin+amikacin) may be administered. Empirical intravenous fluoroquinolone use improved the survival of critically ill patients admitted for pulmonary TB [11]. Several studies have reported that higher than usual doses of anti-TB drugs (e.g.…”