Discussion
respiratory failure, comorbidity, HCAP
RESPIRATORY FAILURE, DISEASE, SEPTIC SHOCK
This study found that almost half of the patients admitted to the ICU due to CAP died within one year after the acute episode. Additionally, patients with a higher Charlson comorbidity index, SAPS II, septic shock, and respiratory failure had a higher probability of dying within one year of the acute CAP hospitalisation in the ICU. After a comprehensive statistical analysis of this large prospective cohort, our results suggest that macrolide-based treatment reduces long-term mortality in patients admitted to the ICU due to CAP. Although results regarding coverage of atypic microorganisms with fluoroquinolones proved to be a protector factor at 6 m, this was a vague association that was not maintained thereafter.Different studies have shown that long-term morbidity and mortality rates in CAP patients are elevated [Several risk factors have been associated with higher mortality in patients with CAP. Regarding severity, the utility of the SAPS II score among long-term outcomes is still debatable [Empiric antibiotic treatment has been described as the cornerstone of CAP management [Our study has certain limitations that are important to acknowledge. First, this is a monocentric, observational, non-randomised study design. However, we included an extensive sample size of over three thousand patients over 10 years. Moreover, we conducted a TMLE (that simulates an RCT) to adjust results for potential confounding variables, controlling the risk of bias and enabling greater statistical power. Second, patients were enrolled in a high-income country, making it difficult to extrapolate and replicate the methodology to validate this data in low- and middle-income countries. However, clarithromycin is an inexpensive medication that could be used in limited-resource settings with myriad potential benefits. Third, no standardised protocols of antimicrobial treatment, doses, start time, and total days of administration were used, which also restricted the stratification analysis by these data. Nevertheless, macrolides are available globally and are used frequently in patients admitted to the hospital in the ICU with CAP using standard dosing. Also, the centres in this study used internationally accepted guidelines for using empirical antibiotics. Finally, we could not differentiate patients diagnosed with HCAP in our cohort. This might be a limitation because patients with HCAP were considered at risk of CAP due to In conclusion, our study used a robust statistical analysis to demonstrate that macrolide-based treatment is associated with lower long-term mortality by reducing over one-third of the hazard risk; therefore, the benefit observed during acute hospitalisation is sustained over time. Thus, these data provide further justification for using macrolide-based treatment in patients with CAP admitted to the ICU to reduce the long-term burden of this prevalent disease. Additional prospective studies are required to support these conclusions.