JAC Advance Access published online on April 14, 2003
Journal of Antimicrobial Chemotherapy, doi:10.1093/jac/dkg220
© 2003 by The British Society for Antimicrobial Chemotherapy
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Original article
1 Department of Epidemiology
and Biostatistics, Case Western Reserve University School of Medicine,
WG-57, 10900 Euclid Avenue, Cleveland, OH 44106; Center
for Quality Improvement Research, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, OH; Center
for Healthcare Research and Policy, MetroHealth Medical Center,
Cleveland, OH, USA
* Corresponding author. E-mail: mes12{at}po.cwru.edu.
Received 29 May 2002
; revised 16 August 2002
; 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
Impact of antimicrobial resistance on health outcomes
in the
out-patient treatment of adult community-acquired pneumonia:
a probability model
2 Micron
Research Ltd, Upwell, Cambridgeshire, UK
3 Department of Pathology, Case Western Reserve University
School of Medicine, Cleveland, OH; Department of Pathology,
University Hospitals of Cleveland, Cleveland, OH, USA
4 Braun School of Public Health
and Community Medicine, Hebrew University of Jerusalem-Hadassah,
Jerusalem, Israel
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