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July 2, 1997

Medical Outcomes and Antimicrobial Costs With the Use of the American Thoracic Society Guidelines for Outpatients With Community-Acquired Pneumonia

Author Affiliations

From the Department of Pharmaceutical Sciences, School of Pharmacy (Dr Gleason), Division of General Intemal Medicine, Department of Medicine (Drs Gleason, Kapoor, and Fine and Mr Obrosky), Departments of Biostatistics (Dr Stone) and Health Services Administration (Dr Lave), Graduate School of Public Health, Department of Psychiatry and University Center for Social and Urban Research (Dr Schulz) and Center for Research on Health Care (Drs Gleason, Kapoor, Lave, Stone, and Fine and Mr Obrosky), University of Pittsburgh, Pittsburgh, Pa; General Internal Medicine Unit, Massachusetts General Hospital, Boston (Drs Singer and Coley); and Division of Infectious Diseases, Department of Medicine, Victoria General Hospital and Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia (Dr Mamie).
Dr Fine has received research support through an educational grant from Pfizer Inc. Dr Singer is receiving research funding from Abbott Laboratories. Dr Marrie has received honoraria from Pfizer Inc and Abbott Laboratories, is receiving a research grant from Pfizer Inc, and was a member of the ATS Consensus panel.

JAMA. 1997;278(1):32-39. doi:10.1001/jama.1997.03550010046038

Context.  —The American Thoracic Society (ATS) published guidelines based on expert opinion and published data—but not clinically derived or validated—for treating adult outpatients with community-acquired pneumonia.

Objective.  —To compare medical outcomes and antimicrobial costs for patients whose antimicrobial therapy was consistent or inconsistent with ATS guidelines.

Design.  —Multicenter, prospective cohort study.

Setting.  —Emergency departments, medical clinics, and practitioner offices affiliated with 3 university hospitals, 1 community teaching hospital, and 1 health maintenance organization.

Participants.  —A total of 864 immunocompetent, adult outpatients with community-acquired pneumonia: 546 aged 60 years or younger with no comorbidity and 318 older than 60 years or with 1 comorbidity or more.

Main Outcome Measures.  —Patients' antimicrobial therapy was classified as being consistent or inconsistent with the ATS guidelines. Mortality, subsequent hospitalization, medical complications, symptom resolution, return to work and usual activities, health-related quality of life, and antimicrobial costs were compared among those treated consistently or inconsistently with the guidelines.

Results.  —Outpatients aged 60 years or younger with no comorbidity who were prescribed therapy consistent with ATS guidelines (ie, erythromycin with some exceptions) had 3-fold lower antimicrobial costs ($5.43 vs $18.51; P<.001) and no significant differences in medical outcomes. Outpatients older than 60 years or with 1 comorbidity or more who were prescribed therapy consistent with ATS guidelines (ie, second-generation cephalosporin, sulfamethoxazole-trimethoprim, orβ-lactam and β-lactamase inhibitor with or without a macrolide) had 10-fold higher antimicrobial costs ($73.50 vs $7.50; P<.001); despite trends toward higher mortality and subsequent hospitalization, no significant differences in medical outcomes were observed.

Conclusion.  —Our findings support the use of erythromycin as recommended by the ATS guidelines for outpatients aged 60 years or younger with no comorbidity. Although the antimicrobial therapy recommended in outpatients older than 60 years or with 1 comorbidity or more is more costly, this observational study provides no evidence of improved medical outcomes in the small subgroup who received ATS guideline—recommended therapy.