Comparison of two guideline-concordant antimicrobial combinations in elderly patients hospitalized with severe community-acquired pneumonia*

Objective: Two of the guideline-concordant therapies for severe community-acquired pneumonia are either a beta-lactam and fluoroquinolone or beta-lactam and macrolide. However it is unclear if there is a benefit for one vs. the other for elderly patients with severe community-acquired pneumonia. Design: A retrospective population-based cohort study of patients with community-acquired pneumonia. Setting: Patients admitted to an intensive care unit of any Department of Veterans Affairs hospital during 5-yr period. Patients: We included only those patients >65 yrs of age admitted to the intensive care unit with community-acquired pneumonia who received either beta-lactam + fluoroquinolone or beta-lactam + macrolide antibiotic therapy for pneumonia. Intervention: Not applicable. Measurements: We used multilevel regression models to examine the effect of beta-lactam + fluoroquinolone vs. beta-lactam + macrolide on each of the outcomes after adjusting for potential confounders using propensity scores. Main Results: The cohort consisted of 1,989 patients: 98.5% male and a mean age of 74 yrs. For treatment, 44% of subjects received beta-lactam + fluoroquinolone and 56% received beta-lactam + macrolide. Unadjusted 30-day mortality was 27% for beta-lactam + fluoroquinolone and 24% for beta-lactam + macrolide (p = .11). In the multilevel models, the use of beta-lactam + fluoroquinolone was not significantly associated with 30-day mortality (odds ratio 1.05, 95% confidence interval 0.85–1.30). However, the use of beta-lactam + fluoroquinolone was significantly associated with increased mean length of stay (incidence rate ratio 1.30, 95% confidence interval 1.27–1.33). Conclusions: We found no significant difference for 30-day mortality but did demonstrate an association with increase in length of stay associated with the use of beta-lactam + fluoroquinolone. Randomized controlled trials are needed to determine the most effective antibiotics regimes for patients with severe pneumonia.

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