Antimicrobial combination treatment including ciprofloxacin decreased the mortality rate of Pseudomonas aeruginosa bacteraemia: a retrospective cohort study

Abstract

Ineffective antimicrobial therapy of Pseudomonas aeruginosa bacteraemia increases mortality. Recent studies have proposed the use of antimicrobial combination therapy composed of a beta-lactam with either ciprofloxacin or tobramycin. To determine if combination therapy correlates to lower mortality and is superior compared to monotherapy, we investigated the effect of antimicrobial treatment regimens on 30-day mortality in a cohort with Pseudomonas aeruginosa bacteraemia. All cases of P. aeruginosa bacteraemia (n = 292) in southwest Skåne County, Sweden (years 2005-2010, adult population 361,112) and the whole county (2011-2012, 966,130) were identified. Available medical and microbiological records for persons aged 18 years or more were reviewed (n = 235). Antimicrobial therapy was defined as empiric at admission or definitive after culture results and was correlated to 30-day mortality in a multivariate regression model. The incidence and mortality rates were 8.0 per 100,000 adults and 22.9% (67/292), respectively. As expected, multiple comorbidities and high age were associated with mortality. Adequate empiric or definitive antipseudomonal treatment was associated with lower mortality than other antimicrobial alternatives (empiric p = 0.02, adj. p = 0.03; definitive p < 0.001, adj. p = 0.007). No difference in mortality was seen between empiric antipseudomonal monotherapy or empiric combination therapy. However, definitive combination therapy including ciprofloxacin correlated to lower mortality than monotherapy (p = 0.006, adj. p = 0.003), whereas combinations including tobramycin did not. Our results underline the importance of adequate antipseudomonal treatment. These data also suggest that P. aeruginosa bacteraemia should be treated with an antimicrobial combination including ciprofloxacin when susceptible.

Fig. 1

Patients included in this study. Flow chart summarising the number of cases in the present study and the reason for exclusion for some analyses

Fig. 2

Pseudomonas aeruginosa bacteraemia incidence increases with age. Incident cases of P. aeruginosa bacteraemia were older (a, bars, left y-axis) than the population in Skåne County (a, curve, right y-axis). In all age groups, the incidence of P. aeruginosa bacteraemia was higher among males than females and increased with higher age (b). No increase in incidence was seen over the entire study period (c, left y-axis), even though the number of analysed blood cultures increased (c, right y-axis)

Fig. 3

Ciprofloxacin-treated cases had a lower 30-day mortality. Thirty-day mortality rates in percent after treatment with ciprofloxacin or other antimicrobial drug as definitive therapy when culture results were available. The results were stratified by age groups (a), comorbidity as defined by the Charlson comorbidity index (CCI) (b) or infection focus (c)