Evolution over a 15-year period of the clinical characteristics and outcomes of critically ill patients with severe community-acquired pneumonia

Abstract

Objectives: To study the characteristics and outcomes of patients in the ICU with severe community-acquired pneumonia (SCAP) over a 15-year surveillance period. Methods: We conducted a retrospective cohort study of episodes of SCAP, and assessed the epidemiology, etiology, treatment and outcomes of patients admitted to the ICU, comparing three periods (1999---2003, 2004---2008 and 2009---2013). Results: A total of 458 patients were diagnosed with SCAP. The overall cumulative incidence was 37.4 episodes/1000 admissions, with a progressive increase over the three periods (P < 0.001). Patients fulfilling the two major IDSA/ATS criteria at admission increased from 64.2% in the first period to 82.5% in the last period (P = 0.005). Streptococcus pneumoniae was the prevalent pathogen. The incidence of bacteremia was 23.1%, and a progressive significant reduction in overall incidence was observed over the three periods (P = 0.02). Globally, 91% of the patients received appropriate empiric antibiotic treatment, increasing from 78.3% in the first period to 97.7% in the last period (P < 0.001). Combination antibiotic therapy (betalactam + macrolide or fluoroquinolone) increased significantly from the first period (61%) to the last period (81.3%) (P < 0.001). Global ICU mortality was 25.1%, and decreased over the three periods (P = 0.001). Conclusions: Despite a progressively higher incidence and severity of SCAP in our ICU, crude ICU mortality decreased by 18%. The increased use of combined antibiotic therapy and the decreasing rates of bacteremia were associated to improved patient prognosis. Evolución durante un período de 15 años de las características clínicas y resultados de los pacientes críticamente enfermos con neumonía comunitaria grave ResumenObjetivos: Estudiar las características y el pronóstico de los pacientes con neumonía grave adquirida en la comunidad ingresados en una unidad de cuidados intensivos (UCI) durante un período de 15 años. Material y métodos: Estudio retrospectivo de una cohorte de pacientes con neumonía grave comunitaria en los que se analizó la evolución en la epidemiología, etiología, tratamiento y pronóstico durante un período de 15 años, comparando 3 períodos (Resultados: Un total de 458 pacientes fueron diagnosticados de neumonía. La incidencia media global durante el período estudiado fue de 37,4 episodios/1.000 ingresos, encontrándose un incremento progresivo durante los 3 períodos estudiados (p < 0,001). Los pacientes que cumplían con los 2 criterios mayores de neumonía grave de la ATS/IDSA aumentaron de un 64,2% en el primer período a un 82,5% en el último período (p = 0,005). Streptococcus pneumoniae fue el microorganismo más frecuente aislado. La incidencia de bacteriemia fue del 23,1%, encontrándose una reducción significativa y progresiva en la incidencia a lo largo de los 3 períodos (p = 0,02). El 91% de los pacientes recibió tratamiento antibiótico empírico apropiado, encontrándose un incremento entre el primer y el último período del 78,3% al 97,7% (p < 0,001). El tratamiento co...

Burden of Community-Acquired Pneumonia and Unmet Clinical Needs

“…One-ninth of patients hospitalized with CAP will need intensive care unit (ICU) admission because of severe respiratory failure, severe sepsis, or septic shock [32,33] and CAP mortality in these patients remains very high, reaching near 50% [32]. A progressively higher incidence of severe CAP was reported in ICU, but the mortality rate had decreased by 18% over a 15-year period [34]. Data reporting on severity could be driven by reimbursement and, therefore, not represent a real increase in severity CAP.…”

Pneumonia as a cardiovascular disease

“…Macrolides are recommended in combination with β‐lactam antibiotics for hospitalized patients independent of the degree of CAP severity . Multiple observational studies suggest that combination of macrolide with β‐lactam antibiotics may benefit patients who are critically ill due to CAP and required ICU admission which may explain the improved outcomes in this group of patients . Macrolide therapy was evaluated in a recent SRMA of observational studies in critically ill patients with CAP and shown to provide a reduction of mortality when compared with therapies that did not include macrolides (risk ratio (RR): 0.75, 95% CI: 0.58–0.96, P = 0.02) .…”

Determining best outcomes from community‐acquired pneumonia and how to achieve them

“…Community‐acquired pneumonia (CAP) is a common cause of death and hospitalization worldwide. Most studies show a steady improvement in mortality rates for CAP over recent decades despite increasing age, comorbidities and more severe disease . This has been attributed to true clinical advances such as use of guideline concordant combination antibiotic therapy and improvements in intensive care.…”

“…Most studies show a steady improvement in mortality rates for CAP over recent decades despite increasing age, comorbidities and more severe disease. [1][2][3] This has been attributed to true clinical advances such as use of guideline concordant combination antibiotic therapy and improvements in intensive care. However, these improvements pale in comparison to those made in acute coronary syndromes and sepsis over the same period.…”