Leyenaar Joanna K, Shieh Meng-Shiou, Lagu Tara, Pekow Penelope S, Lindenauer Peter K
From the *Division of Pediatric Hospital Medicine, Department of Pediatrics, Tufts University School of Medicine, Boston; †Center for Quality of Care Research, Baystate Medical Center, Springfield; ‡Tufts University School of Medicine, Department of Medicine, Boston; §Division of General Medicine, Baystate Medical Center, Springfield; and ¶School of Public Health and Health Sciences, University of Massachusetts, Amherst, MA.
Pediatr Infect Dis J. 2014 Apr;33(4):387-92. doi: 10.1097/INF.0000000000000119.
Guidelines for management of community-acquired pneumonia recommend empiric therapy with a macrolide and beta-lactam when infection with Mycoplasma pneumoniae is a significant consideration. Evidence to support this recommendation is limited. We sought to determine the effectiveness of ceftriaxone alone compared with ceftriaxone combined with a macrolide with respect to length of stay and total hospital costs.
We conducted a retrospective cohort study of children 1-17 years with pneumonia, using Poisson regression and propensity score analyses to assess associations between antibiotic and length of stay. Multivariable linear regression and propensity score analyses were used to assess log-treatment costs, adjusting for patient and hospital characteristics and initial tests and therapies.
A total of 4701 children received combination therapy and 8892 received ceftriaxone alone. Among children 1-4 years of age, adjusted models revealed no significant difference in length of stay, with significantly higher costs in the combination therapy group [cost ratio: 1.08 (95% confidence interval: 1.05-1.11)]. Among children 5-17 years of age, children receiving combination therapy had a shorter length of stay [relative risk: 0.95 (95% confidence interval: 0.92-0.98)], with no significant difference in costs [cost ratio: 1.01 (95% confidence interval: 0.98-1.04)].
Combination therapy did not appear to benefit preschool children but was associated with higher costs. Among school-aged children, combination therapy was associated with a shorter length of stay without a significant impact on cost. Development of sensitive point-of-care diagnostic tests to identify children with M. pneumoniae infection may allow for more focused prescription of macrolides and enable comparative effectiveness studies of targeted provision of combination therapy.
社区获得性肺炎管理指南建议，当肺炎支原体感染为重要考虑因素时，采用大环内酯类药物和β-内酰胺类药物进行经验性治疗。支持该建议的证据有限。我们试图确定单用头孢曲松与头孢曲松联合大环内酯类药物在住院时间和总住院费用方面的有效性。
我们对1 - 17岁的肺炎患儿进行了一项回顾性队列研究，使用泊松回归和倾向评分分析来评估抗生素与住院时间之间的关联。采用多变量线性回归和倾向评分分析来评估治疗费用对数，并对患者和医院特征以及初始检查和治疗进行调整。
共有4701名儿童接受了联合治疗，8892名儿童单用头孢曲松。在1 - 4岁的儿童中，调整后的模型显示住院时间无显著差异，但联合治疗组的费用显著更高[费用比：1.08（95%置信区间：1.05 - 1.11）]。在5 - 17岁的儿童中，接受联合治疗的儿童住院时间较短[相对风险：0.95（95%置信区间：0.92 - 0.98）]，费用无显著差异[费用比：1.01（95%置信区间：0.98 - 1.04）]。
联合治疗似乎对学龄前儿童无益处，但费用更高。在学龄儿童中，联合治疗与较短的住院时间相关，且对费用无显著影响。开发敏感的即时诊断检测方法以识别肺炎支原体感染儿童，可能有助于更有针对性地使用大环内酯类药物，并开展联合治疗靶向提供的比较有效性研究。
