Changes in antibiotic therapy are associated with increased morbidity and mortality in community-acquired pneumonia: Insights from CAPNETZ

Changes in antibiotic therapy of community acquired pneumonia (CAP) seem to occur often and for different reasons. Yet, the frequency, causes' distribution and impact on mortality/morbidity remain unclear. In our study, we analyzed 11,351 cases of CAP from the CAPNETZ study (October 10/2002 to 02/2020), documenting therapy changes within 14 days of diagnosis. In 31.8% of cases the antibiotic regime was changed. Therapy changes associated with death, hospitalization, ICU admission, vasopressor use and oxygen therapy (each p<0.001). CRB-65 score correlated significantly with therapy changes, particularly pneumonia-caused confusion, tachypnea (≥30/min) at diagnosis and age over 65 (each p<0.001). Furthermore, radiological complications (multilobular infiltrates; pleural effusions) were associated with therapy changes. For nursing-dependent patients and those with enteral tube feeding therapy, as well as those with comorbidities (COPD, diabetes, malignant disease) change was reported more frequently. Prior antibiotic therapy and vaccination against pneumococcal infection was associated with lower frequencies of change. Sequence therapy was the most frequent reason for therapy change (41.4%) followed by ineffectiveness (36.1%), de-escalation (14.7%), incompatibility (4.9%), resistance (3.2%) and viral infection (0.2%). Ineffectiveness and resistance were associated with increased mortality; sequence therapy with lower mortality. Change of antibiotic therapy is associated with increased morbidity and mortality in CAP. This study highlights the importance of identifying patients at risk for the effective initiation and guidance of antibiotic therapy.