title: Comparative effectiveness of ceftriaxone in combination with a macrolide compared with ceftriaxone alone for pediatric patients hospitalized with community-acquired pneumonia.
abstract: BACKGROUND
  Guidelines for management of community-acquired pneumonia recommend empiric therapy with a macrolide and beta-lactam when infection with Mycoplasma pneumoniae is a significant consideration. Evidence to support this recommendation is limited. We sought to determine the effectiveness of ceftriaxone alone compared with ceftriaxone combined with a macrolide with respect to length of stay and total hospital costs.
  
  
  METHODS
  We conducted a retrospective cohort study of children 1-17 years with pneumonia, using Poisson regression and propensity score analyses to assess associations between antibiotic and length of stay. Multivariable linear regression and propensity score analyses were used to assess log-treatment costs, adjusting for patient and hospital characteristics and initial tests and therapies.
  
  
  RESULTS
  A total of 4701 children received combination therapy and 8892 received ceftriaxone alone. Among children 1-4 years of age, adjusted models revealed no significant difference in length of stay, with significantly higher costs in the combination therapy group [cost ratio: 1.08 (95% confidence interval: 1.05-1.11)]. Among children 5-17 years of age, children receiving combination therapy had a shorter length of stay [relative risk: 0.95 (95% confidence interval: 0.92-0.98)], with no significant difference in costs [cost ratio: 1.01 (95% confidence interval: 0.98-1.04)].
  
  
  CONCLUSIONS
  Combination therapy did not appear to benefit preschool children but was associated with higher costs. Among school-aged children, combination therapy was associated with a shorter length of stay without a significant impact on cost. Development of sensitive point-of-care diagnostic tests to identify children with M. pneumoniae infection may allow for more focused prescription of macrolides and enable comparative effectiveness studies of targeted provision of combination therapy.
authors.affiliation: From the *Division of Pediatric Hospital Medicine, Department of Pediatrics, Tufts University School of Medicine, Boston; †Center for Quality of Care Research, Baystate Medical Center, Springfield; ‡Tufts University School of Medicine, Department of Medicine, Boston; §Division of General Medicine, Baystate Medical Center, Springfield; and ¶School of Public Health and Health Sciences, University of Massachusetts, Amherst, MA.
authors.forename: Joanna K
authors.initials: JK
authors.lastname: Leyenaar
authors.forename: Meng-Shiou
authors.initials: MS
authors.lastname: Shieh
authors.forename: Tara
authors.initials: T
authors.lastname: Lagu
authors.forename: Penelope S
authors.initials: PS
authors.lastname: Pekow
authors.forename: Peter K
authors.initials: PK
authors.lastname: Lindenauer
mesh_terms: D000293:Adolescent; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D002443:Ceftriaxone / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D017714:Community-Acquired Infections / Q000188:drug therapy* / Q000191:economics / Q000453:epidemiology; D004359:Drug Therapy, Combination; D017721:Hospital Costs; D006801:Humans; D007223:Infant; D007902:Length of Stay; D018942:Macrolides / Q000627:therapeutic use*; D018410:Pneumonia, Bacterial / Q000188:drug therapy* / Q000191:economics / Q000453:epidemiology; D012189:Retrospective Studies; D014481:United States / Q000453:epidemiology
chemical_list: D000900:Anti-Bacterial Agents; D018942:Macrolides; D002443:Ceftriaxone