There was no statistically significant difference between the number of patients who received Sunnybrook guideline-based therapy (33/59 or 56%) and the number who received non-guideline-based therapy (26/59 or 44%) (p = 0.43) (Table 5). There was also no statistically significant difference among the number of patients who received fluoroquinolone monotherapy (15/59 or 25%), the number who received a second- or third-generation cephalosporin plus macrolide (18/59 or 31%), and the number who received non-guideline- based therapy (26/59 or 44%) (p = 0.26). Finally, there was no statistically significant difference among the number of patients who received fluoroquinolonemonotherapy (15/59 or 25%), the number who received a second- or third-generation cephalosporin plus macrolide (18/59 or 31%), the number who received appropriate non-guideline-based therapy (15/59 or 25%), and the number who received inappropriate non-guideline-based therapy (11/59 or 19%) (p = 0.74).
The clinical outcomes and mean cost of therapy were compared for patients receiving levofloxacin monotherapy, second- or third generation cephalo- sporin plus macrolide combination therapy, appropriate non-guideline-based therapy, and inappropriate non-guideline-based therapy (Table 5). There was no statistically significant difference in the numbers of patients with pneumonia severity index IV or V among these 4 treatment regimens (range 6 to 10 patients) (p = 0.99). The duration of inappropriate empiric non-guideline-based therapy was significantly shorter than that of appropriate empiric regimens (p < 0.05). However, the median duration of total antimicrobial therapy was not significantly different among the treatment regimens (range 6 to 8 days, p = 0.67). The cost of fluoroquinolone monotherapy as an initially selected empiric antibiotic regimen was significantly less than the cost of appropriate non-guideline-based therapy (p < 0.05). The costs of all other empiric antibiotic regimens were not significantly different from each other (p > 0.05). The median cost for the total course of antimicrobial treatment for community- acquired pneumonia ranged from $81 to $270 for the 4 types of regimens (p = 0.12). There was a trend for lower cost for the guideline-based regimens relative to appropriate non-guideline-based regimens (p = 0.0504, Mann-Whitney test), although this did not achieve statistical significance. The median acquisition cost for the total duration of guideline-based therapy was $88.20 (range $10.42 to $1536.40) per patient.
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Table 5. Comparison of Initial Empiric Management for 59 Patients with Community-Acquired Pneumonia Admitted to Sunnybrook Health Sciences Centre
Clinical cure rates were at least 80% with all 4 initial empiric management strategies (range 80% to 87%, p = 0.74). Three patients, all of whom had received a course of 6-lactam antimicrobial therapy, experienced Clostridium difficile-associated diarrhea, but because of the low frequency, no statistical analysis was performed (Table 5). None of the patients in this study had community-associated methicillin-resistant S. aureus, according to the Centers for Disease Control and Prevention definition of this condition.