Macrolides reduce mortality in hospitalized bacteremic pneumococcal pneumonia patients

Israel: Researchers from Israel found that empirical therapy with Macrolides like Azithromycin and Roxithromycin has lessened the mortality by 45% in hospitalized bacteremic pneumococcal pneumonia (BPP) without even the necessity for a full course of therapy. The study results were published in the journal Clinical Infectious Diseases. 

Community-acquired pneumonia frequently causes hospitalization and death. Empirical therapy guidelines recommend the use of either combination therapy with a β-lactam and an advanced macrolide (azithromycin or clarithromycin) or mono-therapy with respiratory quinolones in hospitalized community-acquired pneumonia patients. As previous literature suggested lower mortality with advanced macrolides, Michal Chowers and the team from Israel conducted a study to characterize antibiotic treatment patterns and assess the role of quinolones or macrolides in empirical therapy. 

As a part of an ongoing, nationwide, prospective, population-based, active surveillance of pneumococcal bacteremia adult cases data was collected from all 26 hospitals and 1 major outpatient health maintenance organization from 1 July 2009 to 30 June 2017 in Israel. Cases without information on antibiotic treatment were excluded. A BPP case was defined by the isolation of Streptococcus pneumoniae from blood, with infiltrates on imaging. The independent predictors of in-hospital mortality were assessed by logistic regression analysis. 

Key findings: 

• A total of 2016 patients with BPP having a median age was 67.2 years were identified. Among them 55.1% were men.
• Lobar pneumonia was present in 1440 (71.4%), and multi-lobar in 576 (28.6%).
• The Median length of hospital stay was 6 days (IQR 4-11).
• empiric antibiotics with anti-pneumococcal coverage like ceftriaxone were given in 1267 (62.8%) out of a total of 1921 cases (95.3%). 
• The coverage to atypical bacteria was given in 1159 (57.5%), of which 64% were with macrolides.
• A total of 372 (18.5%) required mechanical ventilation, and 397 (19.7%) died.
• Age, being at high-risk for pneumococcal disease, and multi-lobar pneumonia were the independent predictors of mortality.
• The predictors of survival were the female sex and macrolide therapy. 
• Either azithromycin or roxithromycin treatment for as short as two days was a predictor of survival. Quinolone therapy had no effect. 

Thus, a short-duration macrolide therapy was protective against in-hospital mortality in this large cohort of patients with BPP. 

Further reading: Chowers M, Gerassy-Vainberg S, Cohen-Poradosu R, et al. The Effect of Macrolides on Mortality in Bacteremic Pneumococcal Pneumonia: A Retrospective, Nationwide Cohort Study, Israel, 2009-2017. Clin Infect Dis. 2022;75(12):2219-2224. doi: 10.1093/cid/ciac317