Elsevier

Resuscitation

Volume 84, Issue 5, May 2013, Pages 616-619
Resuscitation

Clinical paper
Early antibiotics improve survival following out-of hospital cardiac arrest

https://doi.org/10.1016/j.resuscitation.2012.11.004Get rights and content

Abstract

Introduction

Therapeutic hypothermia (TH) has become standard management following out of hospital cardiac arrest (OHCA). Recent evidence suggests TH increases the incidence of pneumonia. We retrospectively assessed infective indicators after OHCA and evaluated the effect of antibiotics on survival.

Method

We identified all patients admitted to the ICU of a regional primary angioplasty hospital following OHCA from May 2007 to December 2010. We collected demographic and outcome data, evidence of infection and the use of antimicrobial therapy.

Results

138 patients were admitted to ICU following OHCA. The mortality rate was 68.1% with mean ICNARC predicted mortality of 77.5%. Of 138 patients, 135 (97.8%) had at least one positive marker of infection within 72 h.

53 of 138 patients (38.4%) received antibiotics during the first 7 days of their ICU stay. The hospital mortality rate for these patients was significantly less than those not receiving antibiotics (56.6% vs. 75.3%; p = 0.025) with NNT of 5. Multivariate analysis demonstrated that antibiotic use was an independent predictor of survival.

Conclusion

The post-arrest management of OHCA is commonly complicated by infections, the accurate diagnosis of which is impaired by the associated increase in inflammatory markers, body temperature control, delay in the processing of samples and poor quality chest radiography.

We have shown a significant reduction in mortality in patients who received antibiotics compared with patients who did not. This suggests that a formal clinical trial is warranted.

Introduction

Out-of-hospital cardiac arrests (OHCA) are a significant cause of morbidity and mortality. In Europe, there is an estimated annual incidence of 38 per 100,000 population.1 OHCA has a very high mortality rate: 23.4% of OHCA victims make it to hospital alive and only 7.6% survive to hospital discharge.2 Improvements in the “chain of survival” have led to improvements in survival3 and neurological outcome,4 and there is increasing focus on management of the post-cardiac arrest syndrome.5

Recent improvements in post-arrest care include the development of regional cardiac arrest care centres with access to 24 h primary percutaneous coronary intervention (PCI); goal-directed therapy and care bundles; and neuroprotective strategies, particularly therapeutic hypothermia (TH).6, 7 Initial studies showed improvements in survival and good neurological outcome with 24 h of 32–34 °C for VF/VT arrests.8

TH has been incorporated into the European7 and American6 resuscitation guidelines and is now a part of routine care. Concerns have been raised of increased rates of infections post OHCA and TH9 and a recent cohort study showed that TH was an independent risk factor for pneumonia following OHCA, although no adverse effect on mortality was found.10

We were interested in finding out the extent and types of post OHCA infections in our ICU, and the role of antimicrobial therapy in their treatment. We therefore performed a retrospective cohort study to evaluate the incidence of markers of infection and the use and effects of antimicrobial therapy.

Section snippets

Patient identification

The Bristol Royal Infirmary (BRI) is a teaching hospital and regional cardiac centre with a 24 h primary PCI service. All patients admitted to the 15 bed ICU of the BRI following CPR between March 2007 and December 2010 were identified. The search was performed using the ICNARC database and identified all patients admitted to ICU who had received CPR within 24 h preceding admission.

Patients were excluded if they suffered an in-hospital or traumatic cardiac arrest, if they did not suffer cardiac

Results

A total of 260 patients were identified, of which 122 patients were excluded: 13 were incorrectly coded and had no cardiac arrest; 9 patients had inadequate notes for full analysis; and 102 were in hospital at the time of their cardiac arrest. This left 138 patients admitted following OHCA. The mean age of the patients was 61.7 (95% CI ± 2.71), median 63.5 (IQR 54.0–74.3).

The overall hospital mortality rate for these patients was 68.1% (95% CI: 59.9–75.3). The mean ICNARC predicted mortality rate

Discussion

Previous studies have shown that infections, particularly pneumonia, are common following OHCA. The mechanism for this is thought to be aspiration of oro-pharygeal or gastric contents at the time of collapse, when protective airway reflexes are not present. Bronchial contamination is further encouraged by ventilation with mouth-to-mouth, bag-valve-mask or supra-glottic airway devices in the early stages of resuscitation. The organisms detected in this study support this theory.

TH is thought to

Conclusions

Our study raises two important issues. Firstly, it shows the difficulties in detecting infection in the post-arrest period and asks what strategies are available in the future. Secondly, it shows that antibiotic treatment may have a mortality benefit in these patients and we therefore propose undertaking a randomised controlled trial comparing prophylactic antibiotics with placebo.

Conflicts of interest statement

None.

References (16)

There are more references available in the full text version of this article.

Cited by (56)

  • Association of multiple rib fractures with the frequency of pneumonia in the post-resuscitation period

    2022, Resuscitation Plus
    Citation Excerpt :

    Rib fracture is considered a risk factor for pneumonia.28–30 Several studies have reported other risk factors for the development of pneumonia, such as mechanical ventilation, TH, use of muscle relaxants, and lack of prophylactic antibiotics9–15,25–27 However, no studies have evaluated rib fractures as a risk factor for pneumonia in post-CPR patients. Most risk factors were observed in the multiple rib fracture group than in the non-multiple rib fracture group, which may be related to the development of pneumonia.

  • Prophylactic antibiotic use following cardiac arrest: A systematic review and meta-analysis

    2019, Resuscitation
    Citation Excerpt :

    GRADE tables are included in the electronic supplement. The outcome of survival at last recorded time point was reported in eight studies (three RCTs, one observational study with adjusted analysis, three observational studies with unadjusted analysis) comprising 3443 patients.17–19,21,23–25 Studies analysed survival at different time points, namely ITU discharge (three studies), hospital discharge (one study), 28-day (one study), 30-day (two studies), and six-month (one study).

View all citing articles on Scopus

A Spanish translated version of the summary of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2012.11.004.

View full text