azithromycin for pneumonia and decreased mortality

there have been a couple of warning-type articles in the past couple of years about adverse effects of azithromycin, especially cardiac deaths. as i suggested previously (see below), azithromycin is a really important antibiotic, but should be targeted only for significant bacterial infections -- and it seems mostly to be used unnecessarily (see prior blog below). a recent large cohort study did find some increased likelihood of MI but, most significantly, a lower 90-day mortality (see azithromycin decreases mortality in elderly jama 2014 in dropbox, or doi:10.1001/jama.2014.4304).  those on azithro were on combo therapy. others received guideline-concordant therapy. results:

    --retrospective study from 2002-2012 of 73,690 patients older than 65 (mean age 77.8) from 118 VA hospitals who were hospitalized for community-acquired pneumonia, comparing 30- and 90-day outcomes, and matching 31863 on azithromycin vs same number not. high levels of comorbidities: 40% smokers, 52% with COPD, 35% with diabetes, 25% with prior malignancy. 15.9% were admitted to ICU
    --no significant difference in identified potential confounders between groups
    --90-day mortality 27% lower in those on azithro (17.4% on azithro, 22.3% not -- ie, 4.9% absolute diff, with number needed to treat of 21)
    --however, increased odds of MI (17% higher on azithro, 5.1% vs 4.4% -- ie, number needed to harm of 144), though no diff in "any cardiac event", which was 43.0% vs 42.7%, cardiac arrhythmias (25.8% vs 26.0%) or heart failure (26.3% vs 26.2%).

so, very large study, though retrospective. they did try to use propensity score matching to try to control for likely confounders (which, per their analysis, they did well), and as a large study gives lots of support for their conclusions. interesting that there was no increase in arrhythmias in the azithro group, surprising given the likely increase in QTc as suggested below (reminds me of the issue of prolonged QTc with citalopram, also with lack of anticipated clinical endpoints). bottom line: azithro is an important antibiotic to use, but only for significant probable bacterial infections. this also supports the american thoracic society (ATS) and infectious diseases society of america (ISDA) recommendation for patients with comorbidities (as in this study) to use either fluoroquinolone or combo macrolides (azithro is probably the best) with b-lactam (eg high dose amox, amox/clavulanate) to treat community-acquired pneumonia. of note, a couple of studies have found that combo fluoroquinolone/macrolide is better than fluoroquinolone alone, and that b-lactam plus macrolide is better than b-lactam plus fluoroquinolone.  

Comments

Post a Comment

if you would like to receive the near-daily emails regularly, please email me at gmodest@uphams.org

Popular posts from this blog

cystatin c: better predictor of bad outcomes than creatinine

  another article found significant discordance between creatinine and cystatin C in assessing renal function,  finding that the latter correlated most strongly with both renal and non-renal adverse clinical outcomes (see   ckd cystatin c better than creat AJKD2023  in  dropbox or doi: 10.1053/ j.ajkd.2023.04.002)   Details: -- 158,601 adults who were in the Stockholm Creatinine Measurements (SCREAM) project and had testing of creatinine and cystatin C on the same day during a healthcare encounter, from 2010-2018     -- >400,000 outpatient tests were done for both creatinine and cystatin C levels -- mean age 62, 48% female -- mean eGFR by creatinine (   eGFR cr ) 80; mean eGFR by cystatin C ( eGFR cys  ) 73 -- mean stage of renal insufficiency: 39%  eGFR cr   90+; 38%  eGFR cr  60-89; 12%  eGFR cr  45-59; 7.1%  eGFR cr  30-44; 3.2%  eGFR cr  15-29, 0.7%  eGFR cr ...
Read more

diabetes DPP-4 inhibitors and the risk of heart failure

the FDA just came out with a safety alert about 2 DPP-4 inhibitors and the increased risk of heart failure (released 04/05/2016)(see  http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm494252.htm?source=govdelivery&utm_medium=email&utm_source=govdelivery ​ ). details: --saxagliptin and alogliptin were singled out because of 2 clinical trials in diabetic patients with heart disease. in each trial more patients taking these meds were hospitalized for heart failure vs those on placebo     --in the saxagliptin trial: 3.5% were hospitalized for heart failure (vs 2.8% on placebo). risk factors included prior heart failure or kidney disease     --in the alogliptin trial: 3.9% were hospitalized for heart failure (vs 3.3% on placebo) --recommendation by the FDA:     -- we should consider stopping these drugs if the patient develops heart failure ...
Read more

UPDATE: ASCVD risk factor critique

I decided to do an extensive update of my prior ASCVD (atherosclerotic cardiovascular disease) risk analysis and critique of risk calculators, with much more information about the “non-traditional” risk factors. I felt that there should be more data/clarification, since I think we are really undertreating/not preventing the most common cause of death by relying on the current ASCVD risk calculators   -- Cardiovascular risk models:      -- many of us rely on the various cardiovascular risk models to determine the appropriate approach to patients, and these are often integrated into the electronic medical records      -- these risk models have several very important limitations:          -- they are typically based on community data, eg from the Framingham study etc. But, in clinical practice, we are dealing with the individual and not the community:          ...
Read more