NSAIDs May Worsen Pneumonia Outcomes

NEW YORK (Reuters Health) February 11, 2011 — The antipyretic and analgesic benefits of nonsteroidal anti-inflammatory drugs (NSAIDs) early in the course of a severe lower respiratory tract infection might be outweighed by some major disadvantages, French researchers say.
The possible costs? Delayed diagnosis of community-acquired pneumonia and more frequent complications.
In their pilot study, Dr. Muriel Fartoukh and colleagues observed that NSAID-treated patients with community-acquired pneumonia were five times as likely to develop pleural empyema or lung cavitation compared with patients not receiving NSAIDs. NSAIDs were also associated with double the risk of bacteremia, the authors report in the February issue of Chest.
The study took place at the authors' institution, Tenon Hospital in Paris, between 2002 and 2006. The 90 consecutive patients were admitted to the intensive care unit or its affiliated step-down unit. Patients with other severe diseases or who were on long-term NSAID or steroid therapy were excluded.
Thirty-two patients (36%) had been taking NSAIDs either alone (n = 18) or with antibiotics (n = 14) for an average of 5 days prior to referral. Sixteen patients not given NSAIDs had antibiotics prior to admission.
The report shows that patients in the NSAID group tended to have lower severity of disease upon admission, based on lower Simplified Acute Physiologic Score (SAPS) II and Sepsis-related Organ Failure Assessment (SOFA) score. However, they had a higher prevalence of chest pain and pleural syndrome, as well as multilobar infiltrates and pleural effusions on X-rays.
The cause of pneumonia was documented for three-quarters of patients. Most cases were due to Streptococcus pneumoniae, followed by Legionella and Pseudomonas aeruginosa. Four cases were polymicrobial.
Dr. Fartoukh's team notes that causes were similar regardless of NSAID use. In both groups, antibiotic regimens prior to hospital admission were appropriate less than half the time.
Among patients not treated with antibiotics prior to admission, bacteremia was more common in the NSAID group (69% vs. 27%, p = 0.009). NSAIDs were also linked to a higher rate of pleural empyema and lung cavitation (37.5% vs. 7%, p = 0.0009).
On multivariable analysis, NSAID exposure was the only independent predictor of pleuropulmonary complications (odds ratio 8.1), as it was for invasive disease in the absence of preadmission antibiotics (OR 3.8).
NSAIDs were also linked to significantly longer antimicrobial therapy and trends to longer stays in the ICU and in the hospital.
The authors point out that patients on NSAIDs didn't have higher rates of organ failure, greater need for organ support, or more severe systemic inflammation while in the ICU, nor did mortality differ between groups.
Nevertheless, they write, "These findings suggest that NSAID use at the early stage of community-acquired pneumonia can be associated with a less-effective compartmentalization of infection, but a blunted systemic response, which may result in delayed diagnosis and management, and a protracted course."
They suggest that the higher complication rate may have resulted from the longer delay to hospital referral.