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





Fluoroquinolone Monotherapy




2nd-

or
3rd- Generation Cephalosporin


+





Non-guideline-based Therapy





Statistical Analysis*





Macrolide





Appropriate





Inappropriate



No. of patients
(%)


15 (25)


18 (31)


15 (25)


11 (19)




p

> 0.05+


PSI mortality risk
classification


(no. of patients)




p

= 0.99+


Low (I to III)


6


8


6


5


Moderate (IV)


5


7


5


3


High (V)


4


3


4


3


Duration of empiric
therapy (no. of days)


Kruskal-Wallis:

p =

0.004


Median


Mean


SD


5 5 3



  1. 2



  1. 3


1 2 1



Dunn multiple- comparison:
p

< 0.05§


Range


1-9


1-7


1-13


1-4


Cost of empiric therapy
(Can$)



Kruskal-Wallis:
p

= 0.014II


Median


25


85


159


46


Mean


68


115


184


60


SD


85


87


180


48


Range


5-320


25-324


5-746


5-170


Duration of total
antibiotic course (no. of days)



Kruskal-Wallis:
p= 0.67


Median


7


8


8


6


Mean


10


9


8


6


SD


9


6


4


4


Range


3-36


3-22


3-16


2-15


Cost of antibiotic
therapy (Can$)4



Kruskal-Wallis:
p= 0.12


Median


81


91


270


128


Mean


197


273


300


140


SD


284


382


224


107


Range


10-917


25-1536


28-776


12-385


Clinical outcome




p

= 0.74**


Cure


13 (87)


15 (83)


12 (80)


9 (82)


Death


2 (13)


3 (17)


1 (7)


2 (18)


Unknown


2 (13)++




Clostridium difficile-associated



diarrhea (no. of patients)


0


2


1++


0


No statistical analysis

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.
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