Empirical antibiotic therapy for spontaneous intracerebral hemorrhage-associated pneumonia: an ICU-based single-centered retrospective cohort study

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BACKGROUND: Pneumonia is a common and severe complication following spontaneous intracerebral hemorrhage (SICH) and is associated with significantly worse clinical outcomes. However, there remains insufficient evidence supporting empirical antibiotic regimens for SICH-associated pneumonia (SICHAP). OBJECTIVE: To evaluate the clinical efficacy of different empirical antibiotic regimens in patients with SICHAP and to provide evidence for optimizing initial antimicrobial strategies. METHODS: This single-center retrospective cohort study enrolled adult patients with SICH who developed pneumonia within 7 days of onset between July and December 2024. Patients were stratified according to their initial empirical antibiotic regimen: cefazolin (CFZ), ceftriaxone (CRO), cefoperazone-sulbactam (CFP-SUL), or piperacillin-tazobactam (PIP-TAZ). The primary outcome was the clinical efficacy rate at 72 h. The secondary outcomes included the SICHAP treatment failure rate, in-hospital mortality, length of stay, duration of mechanical ventilation, and duration of antibiotic therapy. Treatment appropriateness was assessed on the basis of sputum culture and antimicrobial susceptibility testing. RESULTS: A total of 85 patients (mean age 54.2 ± 13.5 years, 63.5% male) were enrolled, with 90.6% presenting with early SICHAP. The 72-hour efficacy rate in the CFP-SUL group (73.3%) was significantly greater than that in the CFZ group (25.0%), CRO group (54.5%), and PIP-TAZ group (58.8%) (p = 0.022). The overall SICHAP treatment failure rate was 55.3%, with no significant intergroup differences (p = 0.137). In the sputum culture-positive subgroup (n = 49), appropriate empirical antibiotic therapy (AEAT) significantly reduced treatment failure (58.1% vs. 94.4%, p = 0.008). Pathogens were predominantly Gram-negative (75.3%), with the most common isolates being Klebsiella pneumoniae (42.9%), Pseudomonas aeruginosa (40.8%), and Acinetobacter baumannii (22.4%). High rates of ESBL production and carbapenemase detection were observed. CONCLUSION: Among SICHAP patients, empirical CFP-SUL therapy demonstrated greater 72-hour clinical efficacy, and AEATs significantly reduced the risk of treatment failure. These findings suggest that CFP-SUL may be favored for early empirical antimicrobial therapy in this population, although prospective randomized controlled trials are needed to confirm these results. CLINICAL TRIAL: Clinical trial number: not applicable.