阿奇霉素疗法对老年肺炎住院患者的安全性

虽然临床治疗指南建议将大环内酯类（包括阿奇霉素）的联合用药方案作为肺炎住院患者的一线治疗方案，但近期研究表明阿奇霉素可能会增加心血管事件的发生率
重要意义 虽然临床治疗指南建议将大环内酯类（包括阿奇霉素）的联合用药方案作为肺炎住院患者的一线治疗方案，但近期研究表明阿奇霉素可能会增加心血管事件的发生率。

目的 分析阿奇霉素的使用对肺炎住院患者的全因死亡率及心血管事件发生率的影响。

设计 采用回顾性队列研究，对财政年度 2002 至 2012 年间接受阿奇霉素治疗的老年肺炎住院患者与接受指南建议的其他抗生素治疗的患者进行比较。

数据设定 这项研究采用了美国退伍军人事务部所登记的全国荣军急诊医院住院患者数据。

研究参与者 患者的纳入标准为年龄大或等于 65 岁、因肺炎而住院、住院期间接受了符合全国临床治疗指南的抗生素治疗。

主要转归和指标 转归指标包括 30 天和 90 天全因死亡率及 90 天心律失常、心衰、心肌梗死及任意心脏事件发生率。对条件性 Logistic 回归的已知混杂变量之潜在影响，采用倾向度匹配法进行控制。

结果 共有 73690 名来自 118 家医院的患者被筛选出，根据倾向度匹配法，其中有 31963 名患者被分入阿奇霉素治疗组，另外 31863 名相匹配的患者被分入非阿奇霉素治疗组。两组经匹配后在潜在混杂变量方面并不存在显著差异。阿奇霉素组的 90 天死亡率显著低于非阿奇霉素组（阿奇霉素组为 17.4%，非阿奇霉素组为 22.3%；风险比 [OR] 为 0.73；95% CI 为 0.70-0.76）。然而我们发现，阿奇霉素组的心肌梗死风险显著高于非阿奇霉素组（5.1% 对 4.4%; OR, 1.17; 95% CI, 1.08-1.25），但任意心脏事件（43.0% 对 42.7%; OR, 1.01; 95% CI, 0.98-1.05）、心律失常（25.8% 对 26.0%; OR, 0.99; 95% CI, 0.95-1.02）或心衰（26.3% 对 26.2%; OR, 1.01; 95% CI, 0.97-1.04）的发生风险并不存在这一情况。

结论和启示 对老年肺炎住院患者而言，含阿奇霉素的治疗方案与含其他抗生素的治疗方案相比可降低 90 天死亡率，但也会导致心肌梗死风险小幅升高。这些结果表明，阿奇霉素的使用益处大于风险。

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JAMA. 2014 Jun 4;311(21):2199-208. doi: 10.1001/jama.2014.4304.
Association of azithromycin with mortality and cardiovascular events among older patients hospitalized with pneumonia.
Abstract
IMPORTANCE:
Although clinical practice guidelines recommend combination therapy with macrolides, including azithromycin, as first-line therapy for patients hospitalized with pneumonia, recent research suggests that azithromycin may be associated with increased cardiovascular events.
OBJECTIVE:
To examine the association of azithromycin use with all-cause mortality and cardiovascular events for patients hospitalized with pneumonia.
DESIGN:
Retrospective cohort study comparing older patients hospitalized with pneumonia from fiscal years 2002 through 2012 prescribed azithromycin therapy and patients receiving other guideline-concordant antibiotic therapy.
SETTING:
This study was conducted using national Department of Veterans Affairs administrative data of patients hospitalized at any Veterans Administration acute care hospital.
PARTICIPANTS:
Patients were included if they were aged 65 years or older, were hospitalized with pneumonia, and received antibiotic therapy concordant with national clinical practice guidelines.
MAIN OUTCOMES AND MEASURES:
Outcomes included 30- and 90-day all-cause mortality and 90-day cardiac arrhythmias, heart failure, myocardial infarction, and any cardiac event. Propensity score matching was used to control for the possible effects of known confounders with conditional logistic regression.
RESULTS:
Of 73,690 patients from 118 hospitals identified, propensity-matched groups were composed of 31,863 patients exposed to azithromycin and 31,863 matched patients who were not exposed. There were no significant differences in potential confounders between groups after matching. Ninety-day mortality was significantly lower in those who received azithromycin (exposed, 17.4%, vs unexposed, 22.3%; odds ratio [OR], 0.73; 95% CI, 0.70-0.76). However, we found significantly increased odds of myocardial infarction (5.1% vs 4.4%; OR, 1.17; 95% CI, 1.08-1.25) but not any cardiac event (43.0% vs 42.7%; OR, 1.01; 95% CI, 0.98-1.05), cardiac arrhythmias (25.8% vs 26.0%; OR, 0.99; 95% CI, 0.95-1.02), or heart failure (26.3% vs 26.2%; OR, 1.01; 95% CI, 0.97-1.04).
CONCLUSIONS AND RELEVANCE:
Among older patients hospitalized with pneumonia, treatment that included azithromycin compared with other antibiotics was associated with a lower risk of 90-day mortality and a smaller increased risk of myocardial infarction. These findings are consistent with a net benefit associated with azithromycin use.

学习了，谢谢分享

学习了，谢谢分享

很好的文章，谢谢

这个实验的研究人群只是一般的65岁以上人群，如果是存在心脏病的患者，不知道结果会怎么样。药物警戒警示过阿奇霉素可能导致QT间期延长，一直不太敢用于心内科的病人，特别是本身就有QT间期延长的或者存在心动过缓的患者，又或者是合并使用胺碘酮的患者。