Cefepime vs Piperacilina Tazobactam en el manejo empírico de la neumonía adquirida en la comunidad grave en adultos : Un análisis de pareamiento por puntaje de propensión

Abstract

La neumonía adquirida en la comunidad (NAC) grave es una de las principales enfermedades infecciosas que afecta a la población que se encuentra en la Unidad de Cuidados Intensivos (UCI), y en la que el manejo antibiótico empírico para pacientes con factores de riesgo para Pseudomona aeruginosa no está claramente definido en las guías internacionales. Por tanto, el presente estudio tiene como objetivo evaluar el tratamiento antibiótico antipseudomónico para pacientes con NAC grave en la UCI. MATERIALES Y MÉTODOS: se realizó un análisis secundario de una cohorte retrospectiva con un análisis de puntaje de propensión (PSM) en la Clínica Universidad de la Sabana, se toma registro de historias clínicas desde febrero de 2006 a abril del año 2021; dado que la obtención de datos de la base de datos Medical Information Mart for Intensive Care (MIMIC IV) no fue posible. Se incluyeron los pacientes con diagnóstico clínico, paraclínico y radiológico de NAC. Se tuvo en cuenta la asociación de variables demográficas, comorbilidades y resultados clínicos frente a la mortalidad de a Cefepime (CEF) versus Piperazilina Tazobactam (PTZ), el tamaño de muestra calculado por medio de la fórmula de Fleiss debía ser de 600 participantes en total, sin embargo, posterior al emparejamiento 1:1 en el PSM se obtuvo una muestra de 406 pacientes, inferior a la esperada. RESULTADOS: se obtuvo una muestra de 406 pacientes. El promedio de edad de toda la población fue de 70.28 años (DE: 19.5), con mayor frecuencia del sexo masculino para PTZ (51%). %). Las comorbilidades más frecuentes en ambos grupos fueron Hipertensión arterial (HTA) (49% Vs 48%; P=0.2018), y Enfermedad cerebrovascular (ECV) (33% en ambos grupos P=0.9749), la comorbilidad menos frecuente fue SIDA en ambos grupos (P= 0.3178). Después de emparejar, el índice de Rubin disminuyó de 53.4 a 6.2.

INTRODUCTION: Acquired-community pneumonia (ACP) is a main infectious disease that affect in UCI hospitalized people and in which the empirical treatment to patients that have risk factors to Pseudomona aeruginosa isnt clearly define don the international gidelines. The present study has as objective assessment the antibiotic therapy against pseudomona spp on this type of patients. MATERIALS AND METHODS: A secondary analysis of a retrospective cohort was performed with a propensity score analysis (PSM) at the Universidad de la Sabana Clinic, registering medical records from February 2006 to April 2021; since obtaining data from the Medical Information Mart for Intensive Care (MIMIC IV) database was not possible. Patients with a clinical, paraclinical and radiological diagnosis of CAP were included. The association of demographic variables, comorbidities and clinical results with the mortality of Cefepime (CEF) versus Piperaziline Tazobactam (PTZ) was taken into account. The sample size calculated using the Fleiss formula should have been a total of 600 participants; however, after the 1:1 match in the PSM, a sample of 406 patients was obtained, which was lower than expected. RESULTS: a sample of 406 patients was obtained. The average age of the entire population was 70.28 years (SD: 19.5), with a higher frequency of males for PTZ (51%). %). The most frequent comorbidities in both groups were Arterial Hypertension (AHT) (49% Vs 48%; P=0.2018), and Cerebrovascular Disease (CVD) (33% in both groups P=0.9749), the least frequent comorbidity was AIDS in both groups. groups (P= 0.3178). After matching, Rubin's index decreased from 53.4 to 6.2. After propensity score matching, 30-day mortality showed no difference between CEF or PTZ treatment (ATE: 0.051, 95%CI: -0.025-0.127, P=0.189 and ATET: 0.022, 95%CI: -0.061-0.105, P=0.603), CEF has a lower percentage of mortality versus PTZ (18.2% Vs 27.2%; P=0.012), as well as better performance in the survival curve (P=0.014). DISCUSSION: To date, no study has been found in the literature that compares these two antibiotic therapy strategies in patients with severe CAP. This being the first study to compare this antibiotic therapy strategy in this clinical entity. It is found that the study population is elderly, with multiple comorbidities. Mortality obtained by PTZ is similar to that reported in the literature, mortality by CEF is lower than that reported in the literature. The main limitation of the study is the sample size, since with a larger sample size the results could have been significant. CONCLUSIONS: CEF y PTZ are antibiotics that might use in the management acute of ACP to patients with risk factors to Pseudomona aeruginosa indistinctly. A larger sample is needed for the differences between these two antibiotics in this clinical context to be significant.