Marras Theodore K, Jamieson Linda, Chan Charles K
Department of Medicine, University of Toronto, Canada.
Can Respir J. 2004 Mar;11(2):131-7. doi: 10.1155/2004/970828.
Evidence supporting antibiotic treatment guidelines and respiratory quinolones (RQs) in community-acquired pneumonia (CAP) is limited.
To study associations among guideline adherence, specific antibiotics, clinical outcomes and antibiotic costs.
A retrospective cohort study in three tertiary care university teaching hospitals in Toronto, Ontario, studying CAP inpatients between November 1997 and June 2000. The period encompassed 12 months when an early version of empirical antibiotic guidelines was used (early cohort) and 18 months when recent guidelines (including RQs) were used (recent cohort).
Six hundred ninety-eight cases of CAP were reviewed, and 91% were guideline adherent. In multivariable analyses, no association was observed between guideline adherence and mortality or duration of hospitalization. Guideline-adherent cases received fewer antibiotics in both cohorts and 0.9 days less of intravenous antibiotics (P=0.04) in the recent cohort. There was no significant difference in antibiotic cost according to guideline adherence, but recent cohort guideline-adherent cases had lower drug costs than early cohort guideline-adherent cases. Antibiotic selection was associated with illness severity and was mirrored by clinical outcomes, despite controlling for the pneumonia severity index (PSI). Treatment with anaerobic agents (odds ratio 2.7, P=0.001) or cephalosporin plus macrolide (odds ratio 2.7, P=0.02) was associated with higher mortality. Treatment with RQ monotherapy was associated with a 2.3 day shorter duration of intravenous therapy (P<0.0001) and a 19.19 dollars lower total antibiotic cost (P<0.0001).
Findings support empirical treatment guidelines for CAP and their recommendations regarding RQs. The association between mortality and anaerobic coverage or combination therapy may reflect prognostic information available at presentation but not captured by the PSI.
支持社区获得性肺炎（CAP）抗生素治疗指南及呼吸喹诺酮类药物（RQ）的证据有限。
研究指南依从性、特定抗生素、临床结局及抗生素成本之间的关联。
在安大略省多伦多市的三家三级医疗大学教学医院进行一项回顾性队列研究，研究1997年11月至2000年6月期间的CAP住院患者。该时间段包括使用经验性抗生素指南早期版本的12个月（早期队列）和使用近期指南（包括RQ）的18个月（近期队列）。
共审查了698例CAP病例，91%的病例符合指南。在多变量分析中，未观察到指南依从性与死亡率或住院时间之间存在关联。两个队列中，符合指南的病例使用的抗生素较少，近期队列中符合指南的病例静脉使用抗生素的天数少0.9天（P=0.04）。根据指南依从性，抗生素成本无显著差异，但近期队列中符合指南的病例的药品成本低于早期队列中符合指南的病例。抗生素选择与疾病严重程度相关，并反映在临床结局中，尽管对肺炎严重程度指数（PSI）进行了控制。使用厌氧菌制剂治疗（比值比2.7，P=0.001）或头孢菌素加大环内酯类治疗（比值比2.7，P=0.02）与较高的死亡率相关。使用RQ单药治疗与静脉治疗时间缩短2.3天（P<0.0001）和抗生素总费用降低19.19美元（P<0.0001）相关。
研究结果支持CAP的经验性治疗指南及其关于RQ的建议。死亡率与厌氧菌覆盖或联合治疗之间的关联可能反映了就诊时可用但未被PSI捕获的预后信息。
