Outcomes not improved with early amoxicillin-clavulanate in cardiac arrest patients

1. A 2-day course of amoxicillin-clavulanate and targeted temperature management of 32-34 degrees Celsius after cardiac arrest with shockable rhythm resulted in a lower incidence of early ventilator-associated pneumonia than the control group.

2. The intervention did not cause a significant decrease in the rate of late ventilator-associated pneumonia, number of ventilator-free days, ICU length of stay, and mortality at day 28 as compared to the control group.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Survival rates upon discharge among patients with out-of-hospital cardiac arrests is poor, remaining below 20%. In addition, targeted temperature management is recommended in such patients but is associated with increased risk of infection. This randomized controlled trial was designed to test the use of antibiotics plus temperature control to decrease the amount of ventilator-associated pneumonia in patients with out-of-hospital cardiac arrest with a shockable rhythm. A 2-day course of amoxicillin-clavulanate and targeted temperature management of 32-34°C after cardiac arrest with shockable rhythm resulted in a lower incidence of early ventilator-associated pneumonia. A higher frequency of enterobacteria was seen in patients that received amoxicillin-clavulanate. No significant difference was seen between the two groups in the rate of late ventilator-associated pneumonia, number of ventilator-free days, ICU length of stay, and mortality at day 28. Given the small sample size and specific inclusion criteria, further research is required to determine whether antibiotics and targeted temperature control decrease the amount of early ventilator-associated pneumonia in cardiac arrest patients, and if the findings can be applied to other populations.

Click to read the study in NEJM

Relevant Reading: Ventilator Management and Respiratory Care After Cardiac Arrest

In-Depth [randomized controlled trial]: This randomized controlled trial was conducted in France in 16 ICUs from August 2014 to September 2017 to determine the benefit of targeted temperature management plus antibiotics in preventing early ventilator-associated pneumonia for cardiac arrest patients.194 adult patients in the ICU hospitalized for out-of-hospital cardiac arrest with shockable rhythm and treated with 32 to 34°C temperature management were included in this trial. Patients with in-hospital arrests, non-shockable rhythms, ongoing pneumonia, or contraindication to the antibiotics were excluded. Amoxicillin-clavulanate was started within 6 hours after the return of spontaneous circulation and given for 2 days while temperature management was maintained. The incidence of early ventilator-associated pneumonia was lower among patients who received the intervention as compared to the control group (19% vs. 34%; 95% CI 0.31 to 0.92; P=0.03), but the incidence of late ventilator-associated pneumonia was similar between the groups. Overall antibiotic use during the ICU stay tended to be lower for patients in the antibiotic group as compared to the control group (23% vs. 50%). In addition, more gram-negative bacilli cases were seen in the antibiotic group (such as enterobacteria) as compared to the control group. No difference was found in nonpulmonary secondary infections, median number of ventilator-free days, median ICU length of stay, adverse events, and mortality between the two groups.

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