Elsevier

Resuscitation

Volume 92, July 2015, Pages 154-159
Resuscitation

Clinical Paper
Prophylactic antibiotics are associated with a lower incidence of pneumonia in cardiac arrest survivors treated with targeted temperature management

https://doi.org/10.1016/j.resuscitation.2015.01.035Get rights and content

Abstract

Introduction

Prophylactic antibiotics (PRO) reduce the incidence of early-onset pneumonia in comatose patients with structural brain injury, but have not been examined in cardiac arrest survivors undergoing targeted temperature management (TTM). We investigated the effect of PRO on the development of pneumonia in that population.

Methods

We conducted a retrospective cohort study comparing patients treated with PRO to those not receiving PRO (no-PRO) using Northern Hypothermia Network registry data. Cardiac arrest survivors ≥18 years of age with a GCS < 8 at hospital admission and treated with TTM at 32–34 °C were enrolled in the registry. Differences were analyzed in univariate analyses and with logistic regression models to evaluate independent associations of clinical factors with incidence of pneumonia and good functional outcome.

Results

416 of 1240 patients (33.5%) received PRO. Groups were similar in age, gender, arrest location, initial rhythm, and time from collapse to return of spontaneous circulation. PRO patients had less pneumonia (12.6% vs. 54.9%, p < 0.001) and less sepsis (1.2 vs. 5.7%, p < 0.001) compared to no-PRO patients. ICU length of stay (98 vs. 100 h, p = 0.2) and incidence of a good functional outcome (41.1 vs. 36.6%, p = 0.19) were similar between groups. Backwards stepwise logistic regression demonstrated PRO were independently associated with a lower incidence of pneumonia (OR 0.09, 95% 0.06–0.14, p < 0.001) and a similar incidence of good functional outcome.

Conclusions

Prophylactic antibiotics were associated with a reduced incidence of pneumonia but a similar rate of good functional outcome.

Introduction

Targeted temperature management (TTM) as an element of post-resuscitation cardiac arrest care has been associated with improvements in post-discharge neurological function, favorable discharge disposition, and reduced mortality.1, 2, 3, 4 Despite widespread adoption of TTM in this patient population, our understanding of its complications and their impact on clinical outcomes has been slow to evolve.5, 6, 7, 8, 9, 10

Infections, especially early-onset pneumonia, are common complications after cardiac arrest, with or without TTM, though temperature management is believed to exacerbate this problem.11, 12, 13, 14, 15, 16 A two-center study focusing on early-onset pneumonia reported an incidence of 65% among cardiac arrest survivors, many of whom were treated with TTM.17 A more recent multicenter randomized study of TTM after cardiac arrest reported pneumonia occurred in 52% of patients treated at 33 °C and 46% of patients at 36 °C (p = 0.09).18 The incidence of pneumonia during TTM after cardiac arrest exceeds the 9–27% incidence in the general medical–surgical critical care population.19

Prophylactic antibiotics (PRO) have been shown to reduce the incidence of early-onset pneumonia among comatose patients requiring intubation by up to 64% but there are no prospective studies evaluating the effect of PRO on pneumonia incidence or functional outcome in cardiac arrest survivors treated with TTM.20, 21 The objective of this study was to determine if PRO were associated with a lower incidence of pneumonia and improved functional outcome compared to no prophylactic antibiotics (no-PRO) by retrospectively examining the Northern Hypothermia Network registry and to establish effect size to design a prospective randomized trial.

Section snippets

Methods

This retrospective cohort study examined data from the Northern Hypothermia Network, a multinational, web-based registry of post-resuscitation cardiac arrest care with contributions from 38 hospitals in the United States and Europe (Denmark, Germany, Iceland, Luxembourg, Norway, and Sweden). Forty-five percent of the centers were University hospitals, which contributed 73% of the patients. Local institutional review boards approved patient participation, and when required, the national data

Results

Data from 1240 patients were evaluated (Table 1). Patients were 61.0 (±15.8) years of age and predominantly male (71.9%). Patients were treated to target temperatures of 32 °C (n = 73, 5.9%), 33 °C (n = 1061, 85.8%), or 34 °C (n = 103, 8.3%). Maintenance of the target temperature was accomplished with surface cooling in 80% of patients. Serious infection information was available for 1206 (97.3%) patients. Pneumonia was the most common infection which occurred in 40.4% of patients.

Antibiotics were

Discussion

This analysis of a large, multinational registry of cardiac arrest survivors managed with TTM at 32–34 °C demonstrated that patients treated with PRO had less pneumonia, less sepsis, and fewer serious infections, but a similar ICU LOS and incidence of good functional outcome when compared to those who did not receive PRO. In the multivariable models, PRO were independently associated with a lower incidence of pneumonia but were not associated with good functional outcome.

TTM is promising therapy

Conclusions

This large, retrospective study of cardiac arrest survivors treated with TTM to 32–34 °C identified that antibiotic prophylaxis was associated with a 4-fold decrease in the incidence of pneumonia, but not with improved functional outcome. These findings warrant further validation and exploration in a prospective, randomized study.

Conflicts of Interest

No financial support was provided to complete this work.

Kjetil Sunde, MD, PhD has received travel fees and honoraria from Bard Medical. Niklas Nielsen, MD, PhD has received funding for lectures from Bard Medical. Sten Rubertsson, MD, PhD is a consultant for Physiocontrol. For the remaining authors, no conflicts were declared.

Acknowledgements

The Northern Hypothermia Network was supported, in part, by the Scandinavian Critical Care Trials Group and the Scandinavian Society of Anesthesiology and Intensive Care, the Stig and Ragna Gorthon Foundation, the Torsten Birger Segerfalk Foundation, the Laerdal Foundation, the Gyllenstierna Krapperup Foundation (Nyhamnslage, Sweden), and the Skåne County Council's research and development foundation.

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