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The need for macrolides in hospitalised community-acquired pneumonia: propensity analysis

¹ Dept of Medicine E, Rabin Medical Center, Beilinson Campus and Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel. ² University Center for Model-based Medical Decision Support, Aalborg University, Aalborg, Denmark. ³ Dept of Infectious Diseases, Gemelli Hospital, Catholic University, Rome, Italy. ⁴ Dept of Clinical Microbiology and Hospital Hygiene, Freiburg University Hospital, Freiburg, Germany, ⁵ Both authors contributed equally to the manuscript.

CORRESPONDENCE: L. Leibovici, Dept of Medicine E, Rabin Medical Center, Beilinson Hospital, 49100 Petah-Tiqva, Israel. Fax: 972 39376512. E-mail: leibovic{at}post.tau.ac.il

Keywords: ß-Lactams, combination, community-acquired pneumonia, macrolides, monotherapy, propensity score

Received: March 15, 2007
Accepted May 14, 2007

The present study compared ß-lactam macrolide ("combination") therapy versus ß-lactam alone ("monotherapy") for hospitalised community-acquired pneumonia, using propensity scores to adjust for the differences between patients.

A prospective multinational observational study was carried out. Baseline patient and infection characteristics were used to develop a propensity score for combination therapy. Patients were matched by the propensity score (three decimal point precision) and compared with 30-day mortality and hospital stay. The propensity score was used as a covariate in a logistic model for mortality.

Patients treated with monotherapy (n = 169) were older (mean±SD age 70.6±17.3 versus 65.0±19.6 yrs), had a higher chronic diseases score and a different clinical presentation compared with patients treated with combination therapy (n = 282). Unadjusted mortality was significantly higher with monotherapy (37 (22%) out of 169 versus 21 (7%) out of 282). Only 27 patients in the monotherapy group could be matched to 27 patients in the combination group using the propensity score. The mortality in these groups was identical, with three (11%) demises each. The multivariable odds ratio for mortality associated with combination therapy, adjusted for the propensity score and the Pneumonia Severity Index, was 0.69 (95% confidence interval 0.32–1.48).

The benefit of combination therapy versus monotherapy cannot be reliably assessed in observational studies, since the propensity to prescribe these regimens differs markedly.

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