Predictors of intensive care unit admission in patients with Legionella pneumonia: role of the time to appropriate antibiotic therapy

Abstract

Purpose Legionella spp. pneumonia (LP) is a cause of community-acquired pneumonia (CAP) that requires early intervention. The median mortality rate varies from 4 to 11%, but it is higher in patients admitted to intensive care unit (ICU). The objective of this study is to identify predictors of ICU admission in patients with LP. Methods A single-center, retrospective, observational study conducted in an academic tertiary-care hospital in Pisa, Italy. Adult patients with LP consecutively admitted to study center from October 2012 to October 2019. Results During the study period, 116 cases of LP were observed. The rate of ICU admission was 20.7% and the overall 30-day mortality rate was 12.1%. Mortality was 4.3% in patients hospitalized in medical wards versus 41.7% in patients transferred to ICU (p < 0.001). The majority of patients (74.1%) received levofloxacin as definitive therapy, followed by macrolides (16.4%), and combination of levofloxacin plus a macrolide (9.5%). In the multivariate analysis, diabetes (OR 8.28, CI 95% 2.11–35.52, p = 0.002), bilateral pneumonia (OR 10.1, CI 95% 2.74–37.27, p = 0.001), and cardiovascular events (OR 10.91, CI 95% 2.83–42.01, p = 0.001), were independently associated with ICU admission, while the receipt of macrolides/levofloxacin therapy within 24 h from admission was protective (OR 0.20, CI 95% 0.05–0.73, p = 0.01). Patients who received a late anti-Legionella antibiotic (> 24 h from admission) underwent urinary antigen test later compared to those who received early active antibiotic therapy (2 [2–4] vs. 1 [1–2] days, p < 0.001). Conclusions Admission to ICU carries significantly increased mortality in patients with diagnosis of LP. Initial therapy with an antibiotic active against Legionella (levofloxacin or macrolides) reduces the probability to be transferred to ICU and should be provided in all cases until Legionella etiology is excluded.

Epidemiology of Legionnaires’ Disease in Italy, 2004–2019: A Summary of Available Evidence

“…According to the Italian Medicines Agency (i.e., Agenzia Italiana del Farmaco, AIFA in Italian), during the last decade, northern regions have experienced a sustained decrease in daily consumption of antimicrobial drugs having intracellular activity such as Fluoroquinolones (2.5 defined daily doses [DDD]/1000 persons in 2017 compared to 1.6 in 2019). To date, central (3.3 DDD per 1000 persons in 2017, and 2.2 DDD per 1000 persons in 2019) and southern regions (4.0 DDD per 1000 persons in 2017, and 2.9 DDD per 1000 persons in 2019) still report higher consumption rates (see Table A2) [54,55]. As clinical features of LD are quite indistinctive, it is reasonable that a large share of cases occurring in central and southern Italy are still treated with broad-spectrum antimicrobial drugs: as Legionella spp.…”

Diagnostic stewardship based on patient profiles: differential approaches in acute versus chronic infectious syndromes

“…Combining clinical judgment and currently available molecular instruments, an algorithm for the etiological diagnosis of CAP in the context of Covid-19 pandemics is shown in Figure 4. As shown, after the exclusion of SARS-CoV-2 infection, in patients with severe CAP urinary antigen test for Legionella or S. pneumoniae should be performed, because this determination may guide antibiotic therapy [99]. In patients with negative urinary antigen test for Legionella or S. pneumoniae and risk factors for MDRO, rapid multiplex PCR on respiratory specimens for microbial identification and resistance markers should include both carbapenemases and mecA/C detection, that may guide the choice of antimicrobial therapy.…”

Legioneliozė: Etiologija, Diagnostika, Gydymas, Profilaktika

“…Prieš pasirenkant vaistą, svarbu atsižvelgti į pneumonijos sunkumą, paciento gretutines ligas ir epidemiologinę ligoninės situaciją. Optimali gydymo trukmė skiriasi priklausomai nuo pneumonijos sunkumo laipsnio ir pasirinkto antibiotiko (7-21 diena) [18].…”