Comparison of Mortality and Therapy in Community Acquired Pneumonia

Abstract

Background: Community associated pneumonia (CAP) is one the most common causes of hospital admissions, exceeding more than one million per year in the United States, contributing to 3.4% of inpatient mortality. Our objective was to compare 30-day mortality using therapies recommended for treatment of CAP. Methods: A multicenter retrospective analysis from four different hospitals was assessed from 2008 to 2013. The data was obtained from electronic medical records which included more than 70,000 patients. CAP patients were identified using discharge diagnostic codes during the years 2008-2013, as well as receiving therapy with ceftriaxone and azithromycin or a respiratory fluoroquinolone. Demographic data, antibiotic therapy, and Charlson comorbidity score was obtained to compare the study groups. Results: A total of 21,800 patients met the inclusion criteria for CAP. 1,740 patients were excluded as they received both beta-lactams and fluoroquinolones. The study included 20,600 patients. 11,201 patients (55.84%) received ceftriaxone with azithromycin, and 8,859 (44.16%) received fluoroquinolone therapy. The mortality rate for patients who received fluoroquinolone therapy was lower compared to the patients who received ceftriaxone plus azithromycin (3.56% vs 6.71%, p-value <0.001). Conclusions: Our study showed statistically significant lower 30-day mortality using fluoroquinolone therapy compared to ceftriaxone plus azithromycin for treatment of CAP. Prospective blinded randomized control trials would be needed to support this evidence. DOI: 10.18297/jri/vol2/iss2/5 Received Date: July 20, 2018 Accepted Date: August 9, 2018 Website: https://ir.library.louisville.edu/jri Copyright: ©2018 the author(s). This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Affiliations: 1Department of Medicine, Division of Infectious Diseases, Henry Ford Hospital, Detroit MI 2Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD 3Washington University, St. Louis, MO 4Baylor Scott & White Health, Dallas, TX 5Wayne State University School of Medicine, Detroit, MI *Correspondence To: Gina Maki, DO Work Address: Department of Internal Medicine Henry Ford Hospital 2799 West Grand Boulevard Detroit, Michigan, USA. Work Email: gmaki1@hfhs.org Work Phone: 313-916-3623 19 ULJRI Vol 2, (2) 2018 ORIGINAL RESEARCH hospital length of stay, readmission status, and mortality within 30 days was collected from each of the four hospitals’ electronic medical records (EMR). Information was obtained from each participating centers’ EMR which was then entered into a single database. This database included approximately 70,000 patients. Data was de-identified and coded using explicit data specifications and uploaded into one large database. The study protocol was approved by the institutional review board (IRB) at each participating institution. Teleconferences, enrollments reports, and data audits were conducted between the four study sites to ensure uniform data collection. All hospitalized patients in these hospitals between January 1, 2008 and December 30, 2012 with a discharge diagnosis of pneumonia were identified. Patients were included in the present study if: 1) They were aged ≥18 years; 2) They had received either ceftriaxone plus azithromycin, levofloxacin, or moxifloxacin for the duration of the hospitalization with no other antibiotics administered. Exclusion criteria included: 1) Patients who received other antimicrobial agents; 2) Patients with diagnosis of pneumonia with no information on therapy; 3) Patients who received both therapies. The primary outcome of the study was 30-day all-cause mortality. In hospital mortality was used as a marker for 30-day mortality, as our database was unable to assess 30-day mortality. The patients’ severity of comorbidities was assessed using Charlson comorbidity index. Statistical Methods Univariate statistical analysis was used to test the association of demographic and clinical characteristics with all-cause discharge mortality. Categorical variables were analyzed using the Chi-squared test or Fisher’s exact test. Continuous variables were analyzed using an unpaired t-test. All variables with a p-value < 0.05 in the univariate analysis were included into the multivariate logistic regression. The stepwise selection method was performed to generate the final model (P≤0.05 required for variable entry, P≤0.10 required for variable removal). All p-values were two-sided. Analyses were performed by using SAS 9.4.