title: Impact of guideline-concordant antibiotics and macrolide/β-lactam combinations in 3203 patients hospitalized with pneumonia: prospective cohort study.
abstract: For patients hospitalized with pneumonia, guidelines provide empirical antibiotic recommendations and some studies suggest that macrolide/β-lactam combinations are preferable. We hypothesized that guideline-concordant regimens, particularly macrolide/β-lactams, would reduce mortality and ICU admissions. All patients hospitalized with pneumonia in Edmonton, Alberta, Canada, were managed according to a clinical pathway and enrolled in a population-based registry. Clinical data, Pneumonia Severity Index and treatments were collected. Guideline-concordant regimens were macrolides/β-lactams or respiratory fluoroquinolone monotherapy. The main outcome was in-hospital mortality. The study included 3203 patients and most had severe pneumonia (63% PSI Class IV-V). Three hundred and twenty-one (10.0%) patients died, 306 (9.6%) were admitted to the ICU and 570 (17.8%) achieved the composite of death or ICU admission. Most (n = 2506) patients received guideline-concordant antibiotics. Receipt of guideline-concordant antibiotics was not associated with a reduction in mortality alone (231 (9.2%) vs. 90 (12.9%); adjusted odds ratio (aOR), 0.82; 95% CI, 0.61-1.09; p 0.16), but was associated with decreased death or ICU admission (14.7% vs. 29.0%; aOR, 0.44; 95% CI, 0.36-0.54; p < 0.0001). Within guideline-concordant subgroups, there was no difference in mortality between macrolide/β-lactams and respiratory fluoroquinolone monotherapy (22 (8.3%) vs. 209 (9.3%); aOR, 1.09; 95% CI, 0.66-1.81; p 0.73) but macrolide/β-lactams were associated with increased odds of death or ICU admission (17.4% vs. 14.4%; aOR, 1.58; 95% CI, 1.09-2.27; p 0.01). In conclusion, guideline-concordant antibiotics were not associated with decreased mortality for patients hospitalized with pneumonia, but were associated with a decrease in the composite endpoint of death or ICU admission. Our findings do not support any clinical advantage of macrolide/β-lactam compared with respiratory fluoroquinolone monotherapy.
authors.affiliation: The Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Canada.
authors.forename: L
authors.initials: L
authors.lastname: Asadi
authors.forename: D T
authors.initials: DT
authors.lastname: Eurich
authors.forename: J M
authors.initials: JM
authors.lastname: Gamble
authors.forename: J K
authors.initials: JK
authors.lastname: Minhas-Sandhu
authors.forename: T J
authors.initials: TJ
authors.lastname: Marrie
authors.forename: S R
authors.initials: SR
authors.lastname: Majumdar
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000416:Alberta; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D015331:Cohort Studies; D004359:Drug Therapy, Combination / Q000379:methods; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D018942:Macrolides / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D018410:Pneumonia, Bacterial / Q000188:drug therapy* / Q000401:mortality; D011446:Prospective Studies; D012720:Severity of Illness Index; D016019:Survival Analysis; D016896:Treatment Outcome; D047090:beta-Lactams / Q000627:therapeutic use*
chemical_list: D000900:Anti-Bacterial Agents; D018942:Macrolides; D047090:beta-Lactams