Medical resource utilization among community-acquired pneumonia patients initially treated with levofloxacin 750 mg daily versus ceftriaxone 1000 mg plus azithromycin 500 mg daily: A US-based study^*

ABSTRACT

Objective: The 2007 American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) guidelines recommend that community-acquired pneumonia (CAP) patients admitted to hospital wards initially receive respiratory fluoroquinolone monotherapy or β-lactam plus macrolide combination therapy. There is little evidence as to which regimen is preferred, or if differences in medical resource utilization exist between therapies. Thus, the authors compared length of hospital stay (LOS) and length of intravenous antibiotic therapy (LOIV) for patients who received initial levofloxacin 750 mg daily versus ceftriaxone 1000 mg plus azithromycin 500 mg daily (‘combination therapy’).

Research design and methods: Adult hospital CAP cases from January 2005 to December 2007 were identified by principal discharge diagnosis code. Patients with a chest infiltrate and medical notes indicative of CAP were included. Direct intensive care unit admits and healthcare-associated cases were excluded. A propensity score technique was used to balance characteristics associated with initial antimicrobial therapy using multivariable regression to derive the scores. Propensity score categories, defined as propensity score quintiles, rather than propensity scores themselves, were used in the least squares regression model to assess the impact of LOS and LOIV.

Results: A total of 495 patients from six hospitals met study criteria. Of these, 313 (63%) received levofloxacin and 182 (37%) received combination therapy. Groups were similar with respect to age, sex, most comorbidities, presenting signs and symptoms, and Pneumonia Severity Index (PSI) risk class. Patients on combination therapy were more likely to have heart failure and receive pre-admission antibiotics. Adjusted least squares mean (±SE) LOS and LOIV were shorter with levofloxacin versus combination therapy: LOS, 4.6 ± 0.17 vs. 5.4 ± 0.22 days, p < 0.01; and LOIV, 3.6 ± 0.17 vs. 4.8 ± 0.21 days, p < 0.01. Results for PSI risk class III or IV patients were: LOS, 5.0 ± 0.30 vs. 5.9 ± 0.37 days, p = 0.07; and LOIV, 3.7 ± 0.33 vs. 5.2 ± 0.39 days, p < 0.01. Due to the retrospective study design, limited sample size, and scope (single health-network), the authors encourage replication of this study in other data sources.

Conclusions: Given the LOS and LOIV reductions of 0.8 and 1.2 days, respectively, utilization of levofloxacin 750 mg daily for CAP patients admitted to the medical floor has the potential to result in substantial cost savings for US hospitals.

Key words: :

• Beta-lactam
• Clinical practice guidelines
• Community-acquired pneumonia
• Fluoroquinolone
• Length of stay
• Macrolide

Acknowledgments

Declaration of interest: Funding for this study was provided by Ortho McNeil Janssen Scientific Affairs, LLC. The study was designed locally, and all data were collected and analyzed by the local investigators. The paper was written by the first author with comments from all coauthors. The sponsor set no limitations on study content. C. R. F. has received research grants and/or served as a scientific consultant for AstraZeneca, Elan, and Ortho McNeil Janssen Pharmaceuticals. M. I. R. is on the speaker's bureaus of Ortho-McNeil Janssen, Johnson & Johnson, Pfizer, and BARD, Inc. He has also served on Advisory Boards for Ortho-McNeil Janssen, Johnson & Johnson, Pfizer, and BARD, Inc. M. K. R., S. H. M., A. F., and J. R. S. are employees of Ortho-McNeil Janssen Scientific Affairs, LLC. T. C. J., E. M. M., C. U. O., J. L. R., R. T. A., and B. R. M. and A. D. R. have nothing to disclose related to the content of this manuscript. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.

Notes

* Some of the data in this manuscript were presented, in part, at the American Society of Health-System Pharmacists Summer Meeting, June 8–11, 2008, Seattle, WA, USA and at the 43rd American Society of Health-System Pharmacists Midyear Clinical Meeting and Exhibition, December 7–11, 2008, Orlando, FL, USA