JAC Advance Access originally published online on April 14, 2003
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Journal of Antimicrobial Chemotherapy (2003) 51, 1269-1282
© 2003 The British Society for Antimicrobial Chemotherapy
Impact of antimicrobial resistance on health outcomes in the out-patient treatment of adult community-acquired pneumonia: a probability model
1 Department of Epidemiology and Biostatistics, Case Western Reserve University School of Medicine, WG-57, 10900 Euclid Avenue, Cleveland, OH 44106; 2 Center for Quality Improvement Research, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, OH; 3 Center for Healthcare Research and Policy, MetroHealth Medical Center, Cleveland, OH, USA; 4 Micron Research Ltd, Upwell, Cambridgeshire, UK; 5 Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, OH; 6 Department of Pathology, University Hospitals of Cleveland, Cleveland, OH, USA; 7 Braun School of Public Health and Community Medicine, Hebrew University of Jerusalem–Hadassah, Jerusalem, Israel
Received 29 May 2002; returned 16 August 2002; revised 17 February 2003; accepted 18 February 2003
Out-patient treatment of community-acquired pneumonia (CAP) is a major challenge in an era of increasing prevalence of antimicrobial resistance. However, data describing the clinical impact of such resistance are scarce. A probability model was developed to estimate the impact of antimicrobial resistance on clinical outcomes for adults with CAP, eligible for out-patient care. The model assumed patients would be evaluated at 48–72 h, with those failing to improve being either hospitalized or switched to a different antibiotic. Two strategies were considered: amoxicillin followed by erythromycin (amoxicillin/erythromycin) and erythromycin followed by levofloxacin (erythromycin/levofloxacin). Analyses were conducted based on susceptibility of the major pathogens in France and the UK. Primary model-generated outcome measures were the proportion of patients successfully treated with first-line therapy and the proportion of patients subsequently hospitalized. The model estimated that in France, the amoxicillin/erythromycin strategy would lead to 67.8% improving within 48–72 h and 12.7% subsequently being hospitalized, compared with 48.6% and 13.7% for erythromycin/levofloxacin. For the UK, first-line success and hospitalization rates were, respectively, 71.7% and 8.1% for amoxicillin/erythromycin, and 65.3% and 9.3% for erythromycin/levofloxacin. The model estimated that antimicrobial resistance was responsible for >40% of hospitalizations in France and 15% in the UK. These data suggest that in areas with substantially reduced levels of susceptibility, antimicrobial resistance may be a significant contributor to subsequent hospitalization in adults initially treated as out-patients for CAP. Choice of out-patient treatment strategy should consider local resistance rates in order to maximize the likelihood of early cure, thereby minimizing hospitalizations.
Keywords: community-acquired pneumonia, antimicrobial resistance, patient outcomes, Streptococcus pneumoniae, Haemophilus influenzae
* Corresponding author. Tel: +1-216-368-1951; Fax: +1-216-368-3036; E-mail: mes12{at}po.cwru.edu
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