J Korean Med Sci.  2023 Oct;38(41):e353. 10.3346/jkms.2023.38.e353.

Empiric Anti-Pseudomonal β-Lactam Monotherapy Versus Fluoroquinolone Combination Therapy in Patients With Hospital-Acquired Pneumonia: A Multicenter Cohort Study With Propensity Score Matching

• Baek MS
• Baek AR
• Hong SB
• Bae S
• Park HK
• Kim C
• Lee HK
• Cho WH
• Kim JH
• Chang Y
• Lee HB
• Gil HI
• Shin B
• Yoo KH
• Moon JY
• Oh JY
• Min KH
• Jeon K
• on behalf of the Korean HAP/VAP Study Group

• KMID: 2547180
• DOI: http://doi.org/10.3346/jkms.2023.38.e353

Abstract

Background
There is insufficient data on the benefits of empiric antibiotic combinations for hospital-acquired pneumonia (HAP). We aimed to investigate whether empiric antipseudomonal combination therapy with fluoroquinolones decreases mortality in patients with HAP.
Methods
This multicenter, retrospective cohort study included adult patients admitted to 16 tertiary and general hospitals in Korea between January 1 and December 31, 2019. Patients with risk factors for combination therapy were divided into anti-pseudomonal non-carbapenem β-lactam monotherapy and fluoroquinolone combination therapy groups. Primary outcome was 30-day mortality. Propensity score matching (PSM) was used to reduce selection bias.
Results
In total, 631 patients with HAP were enrolled. Monotherapy was prescribed in 54.7% (n = 345) of the patients, and combination therapy was prescribed in 45.3% (n = 286). There was no significant difference in 30-day mortality between the two groups (16.8% vs. 18.2%, P = 0.729) or even after the PSM (17.5% vs. 18.2%, P = 0.913). After the PSM, adjusted hazard ratio for 30-day mortality from the combination therapy was 1.646 (95% confidence interval, 0.782–3.461; P = 0.189) in the Cox proportional hazards model. Moreover, there was no significant difference in the appropriateness of initial empiric antibiotics between the two groups (55.0% vs. 56.8%, P = 0.898). The proportion of multidrug-resistant (MDR) pathogens was high in both groups.
Conclusion
Empiric anti-pseudomonal fluoroquinolone combination therapy showed no survival benefit compared to β-lactam monotherapy in patients with HAP. Caution is needed regarding the routine combination of fluoroquinolones in the empiric treatment of HAP patients with a high risk of MDR.

Keyword

Healthcare-Associated Pneumonia; Pneumonia; Ventilator-Associated; Anti-Bacterial Agents; Fluoroquinolones; Drug Resistance; Multiple; Mortality

Figure

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  Fig. 1 Flow chart of study design and patient selection.HAP = hospital-acquired pneumonia.

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  Fig. 2 Kaplan-Meier curve analysis for 30-day mortality. (A) Before PSM in the overall cohort (log-rank P = 0.720). (B) After PSM in the overall cohort (log-rank P = 0.960). (C) Microbiologically documented patients (log-rank P = 0.075). (D) Clinically documented patients (log-rank P = 0.420).PSM = propensity score matching.

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