阿奇霉素对治疗老年肺炎住院患者有益

据JAMA上报告的一项大型回顾性队列研究，使用阿奇霉素治疗老年肺炎患者可导致死亡风险下降，心肌梗死风险略有增高。

尽管推荐将阿奇霉素联合大环内酯类抗生素作为肺炎住院患者的一线治疗方案，但近期有研究结果表明阿奇霉素治疗可引起心血管事件的发生风险增加。不过，由退伍军人事务部驻达拉斯的北德克萨斯医疗卫生系统的Eric M. Mortensen医生及其同事进行的这项研究表明，尽管该药可导致心肌梗死风险略有增加（产生危害需治疗的人数为144），但并非 “任何心脏事件”、心律失常或是心力衰竭的风险均增加，而90天死亡风险的下降（需治疗的人数为21）足以抵消其产生的不良影响，形成总的净收益。

Dr. Eric M. Mortensen

在本研究中，受试者为退伍军人事务部行政数据库中记录的在2002~2012年间因肺炎住院、平均年龄为77.8岁的患者。31,863例年龄≥65岁、接受阿奇霉素治疗的患者90年死亡率明显低于同等人数的未以此药物治疗的倾向性治疗匹配对照（17.4% vs. 22.3%；比值[OR ]比， 0.73）不过其心肌梗死的风险明显增加（5.1% vs. 4.4%；OR，1.17）。使用阿奇霉素被定义为患者在入院后48小时内至少接受了1剂阿奇霉素用药。

本研究的受试者中女性相对较少，依赖于ICD-9的规定而非临床资料诊断心血管事件，这或可影响到心力衰竭的诊断。不过， 治疗医生很可能认为研究中的患者确实患有肺炎，没有显示任何对阿奇霉素治疗的偏倚。

新闻视点

心脏病发作风险略有增加，死亡风险显著下降

W. Michael Alberts医生认为，阿奇霉素是一种应用广泛且有效的抗生素，常用于治疗呼吸系统疾病。不过，最近的报告使其安全性遭受质疑。这项大型研究结果或许可以减轻医生心理上的不安，至少在治疗肺炎住院患者时如此。

阿奇霉素治疗使心脏病发作风险略有增加，但能显著降低死亡风险。只要该药在其合理的适应证下应用，我在大多数场合下都会表示赞同。

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Treating pneumonia with azithromycin is linked to lower risk of death but a slightly higher risk of myocardial infarction in older patients, according to a large retrospective cohort study.

Although azithromycin is recommended in combination with macrolides for the first-line treatment of patients hospitalized with pneumonia, recent research suggests that azithromycin is associated with an increased risk of cardiovascular events.

However, the current findings suggest that although the drug is associated with a slight increase in the risk of myocardial infarction (number needed to harm equals 144), it is not associated with "any cardiac event," cardiac arrhythmia, or heart failure, and that the reduction in 90-day mortality risk (number needed to treat of 21) is large enough to provide an overall net benefit.

Dr. Eric M. Mortensen of the Veterans Affairs North Texas Health Care system, Dallas, and his colleagues reported their findings on treating pneumonia with azithromycin in JAMA.

In the current study, 90-day mortality in 31,863 patients aged 65 years and older who were exposed to azithromycin was significantly lower than in an equal number of propensity-matched controls who were not exposed (17.4% vs. 22.3%; odds ratio, 0.73).

The risk of myocardial infarction, however, was significantly increased in the azithromycin group (5.1% vs. 4.4%; OR, 1.17), the investigators reported.

Azithromycin use was defined as patients’ receipt of at least one dose of azithromycin during the first 48 hours after admission.

Study subjects were a mean age of 77.8 years in the national Department of Veterans Affairs administrative database who were hospitalized with pneumonia between 2002 and 2012 (JAMA 2014 June 4 [doi: 10.1001/jama.2014.4304]). Most patients (98%) were male.

The study hadarelativelysmall number of few female subjects and relied "upon ICD-9 diagnosis of cardiovascular events rather than clinical information, which particularly may affect the diagnosis of heart failure." However, researchers said, treating physicians were likely to have believed that the patients in the study indeed had pneumonia and did not show any bias toward azithromycin.

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Slightly increased heart attack risk, significantly lower risk of death

Dr. W. Michael Alberts, FCCP, comments: Azithromycin is a widely used (perhaps too widely) and effective (it’s hard to be too effective) antibiotic commonly used in patients with respiratory illnesses. Recent reports, however, have called the safety of this medication into question. The results of this very large study may ease the practitioner’s anxiety, at least when treating patients hospitalized with pneumonia.

For a slight increased risk of heart attack, use of azithromycin provides a significantly lower risk of death. As long as the drug is used for the appropriate indication, I’ll take that deal in most situations.