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Patrick P. Gleason, PharmD; Thomas P. Meehan, MD, MPH; Jonathan M. Fine, MD; Deron H. Galusha, MS; Michael J. Fine, MD, MSc

Arch Intern Med. 1999;159:2562-2572.

Background  Although medical practice guidelines exist, there have been no large-scale studies assessing the relationship between initial antimicrobial therapy and medical outcomes for patients hospitalized with pneumonia.

Objective  To determine the associations between initial antimicrobial therapy and 30-day mortality for these patients.

Methods  Hospital records for 12,945 Medicare inpatients (65 years of age) with pneumonia were reviewed. Associations between initial antimicrobial regimens and 30-day mortality were assessed with Cox proportional hazards models, adjusting for baseline differences in patient characteristics, illness severity, and processes of care. Comparisons were made with patients treated with a non-pseudomonal third-generation cephalosporin alone (the reference group).

Results  Initial treatment with a second-generation cephalosporin plus macrolide (hazard ratio [HR], 0.71; 95% confidence interval [CI], 0.52-0.96), a non-pseudomonal third-generation cephalosporin plus macrolide (HR, 0.74; 95% CI, 0.60-0.92), or a fluoroquinolone alone (HR, 0.64; 95% CI, 0.43-0.94) was independently associated with lower 30-day mortality. Adjusted mortality among patients initially treated with these 3 regimens became significantly lower than that in the reference group beginning 2, 3, and 7 days, respectively, after hospital admission. Use of a -lactam/-lactamase inhibitor plus macrolide (HR, 1.77; 95% CI, 1.28-2.46) and an aminoglycoside plus another agent (HR, 1.21; 95% CI, 1.02-1.43) were associated with an increased 30-day mortality.

Conclusions  In this study of primarily community-dwelling elderly patients hospitalized with pneumonia, 3 initial empiric antimicrobial regimens were independently associated with a lower 30-day mortality. The more widespread use of these antimicrobial regimens is likely to improve the medical outcomes for elderly patients with pneumonia.

From the Department of Pharmaceutical Care and Health Systems, College of Pharmacy, University of Minnesota, Minneapolis (Dr Gleason); Qualidigm (formally known as the Connecticut Peer Review Organization), Middletown, Conn (Drs Meehan and J. M. Fine and Mr Galusha); Section of Pulmonary and Critical Care Medicine, Norwalk Hospital, Norwalk, Conn (Dr J. M. Fine); and Division of General Internal Medicine, Department of Medicine, and Center for Research on Health Care, University of Pittsburgh, Pittsburgh, Pa (Dr M. J. Fine).

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