Azithromycin linked with decreased mortality in elderly pneumonia patients

1. Azithromycin use was associated with decreased mortality in elderly patients hospitalized for pneumonia compared to treatment regimens with other antibiotics. 

2. Azithromycin use was associated with an increased risk of myocardial infarction but not other cardiac events. No such association was seen in the female subgroup. 

Evidence Rating Level: 2 (Good) 

Study Rundown: The 2007 American Thoracic Society/guidelines recommend the use of macrolides, such as azithromycin, in the treatment of community-acquired pneumonia (CAP). There is inconclusive evidence surrounding the use of azithromycin in hospitalized patients 65 years and older with CAP. This retrospective cohort study compared elderly patients admitted for CAP and treated with antibiotic regimens that included azithromycin versus elderly patients treated with antibiotics regimens that did not include azithromycin. This study found that azithromycin use was associated with decreased all-cause mortality but was associated with increased risk of myocardial infarction. In contrast to the entire cohort, women did not have an increased risk of any cardiac events.

While this study supports the recommended guidelines, it has numerous limitations. Men and women were analyzed together in the primary analysis even though subgroup analysis showed that the small number of women in the study (~2%) responded differently to azithromycin than men. Because of the small sample size, it is not possible to determine if women react substantially differently to azithromycin than men. The study also did not account for duration of therapy, a significant factor in any outcome. Outpatient cardiac events were not recorded.

Click to read the study, published today in JAMA

Relevant Reading: Efficacy of azithromycin in the treatment of community-acquired pneumonia, including patients with macrolide-resistant Streptococcus pneumoniae infection

In-Depth [retrospective cohort]: This study used the Veterans’ Affairs database from 118 hospitals between the years 2001 to 2012. Adults 65 years or older treated with azithromycin upon admission with a diagnosis of pneumonia (n = 38787) were compared with those treated with another macrolide (n = 34903). Following matching for known/measured confounders, 31863 patients from each group were assessed for the primary outcomes of 30- and 90-day mortality and cardiovascular events within 90 days of admission. Subgroup analysis was performed on the entire unmatched cohort.

Azithromycin users had lower mortality at both 30 and 90 days. At 90 days, 17.4% of azithromycin users (95% CI, 17.0% – 17.9%) had died compared to 22.3% (95% CI, 21.8% – 22.7%) of those treated with another macrolide (p<0.001). Azithromycin users had a higher risk of myocardial infarction (OR, 1.17; 95% CI, 1.08 – 1.25) but not cardiac failure or arrhythmia. Subgroups of patients with prior antibiotic use, cardiac disease, diabetes, ICU admission and need for mechanical ventilation displayed similar results as the entire cohort. However, women treated with azithromycin (n = 638) did not have an increased risk of myocardial infarction (OR, 0.80; 95% CI, 0.36 – 1.79).

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