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Nearly one in four adult outpatients with CAP fail antibiotic therapy
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Approximately one in four adult outpatients prescribed antibiotic therapy for community-acquired pneumonia did not adequately respond to treatment, according to data presented at the 2017 American Thoracic Society International Conference.
“Pneumonia is the leading cause of death from infectious disease in the United States, so it is concerning that we found nearly one in four patients with community-acquired pneumonia (CAP) required additional antibiotic therapy, subsequent hospitalization or Emergency Room evaluation,” lead study author James A. McKinnell, MD, assistant professor of medicine, at David Geffen School of Medicine, University of California, Los Angeles, and infectious disease specialist at LA BioMed, said in a press release. “The additional antibiotic therapy noted in the study increases the risk of antibiotic resistance and complications like Clostridium difficile infection, which is difficult to treat and may be life-threatening, especially for older adults.”
According to the researchers, current CAP recommendations from the American Thoracic Society and Infectious Diseases Society of America provide clinicians with some guidance in the treatment of patients with CAP. However, they noted that large-scale, “real-world” data are needed to validate antibiotic choice and define risk factors potentially associated with treatment failure.
McKinnell and colleagues conducted a retrospective cohort analysis using Commercial and Medicare Supplemental Databases to assess treatment outcomes in 251,947 adult patients who were prescribed antibiotic monotherapy for CAP in an outpatient setting between 2011 and 2015. They defined treatment failure as hospitalization or having to refill a prescription, switch antibiotic therapy or visit the ED within 30 days of receiving the initial therapy.
Overall, the rate of treatment failure was 22.1%. Of the patients who failed treatment, 20.6% had their prescription refilled, 70.7% switched antibiotics, 3.3% visited the ED and 5.4% were hospitalized.
After adjusting for patient characteristics, antibiotics associated with the highest failure rate were beta-lactams (25.7%), followed by macrolides (22.9%), tetracyclines (22.5%) and fluoroquinolones (20.8%).
The researchers found that a diagnosis of pneumococcal pneumonia (P < .02), older age (P < .0001) and female gender (P < .0001) were multivariate predictors of treatment failure. In addition, various comorbidities were associated with higher failure rates, including hemiplegia/paraplegia (OR = 1.33; 95% CI, 1.17-1.51), rheumatologic disease (OR = 1.28; 95% CI, 1.21-1.35), chronic pulmonary disease (OR = 1.25; 95% CI, 1.21-1.29), cancer (OR = 1.14; 95% CI, 1.09-1.18), diabetes (OR = 1.07; 95% CI, 1.04-1.1) and asthma (OR = 1.05; 95% CI, 1.01-1.1).
“Our findings suggest that the CAP treatment guidelines should be updated with more robust data on risk factors for clinical failure,” McKinnell said in the release. “Our data provide numerous insights into characteristics of patients who are at higher risk of complications and clinical failure.”
According to McKinnell, the most striking association was observed between age and hospitalization. A risk-adjusted analysis showed that patients older than 65 years were nearly twice as likely to be hospitalized than younger patients.
“Elderly patients are more vulnerable and should be treated more carefully, potentially with more aggressive antibiotic therapy,” he said in the release.
McKinnell also stated that there were substantial regional variations in treatment outcomes and that thousands of patients with other conditions such as chronic obstructive pulmonary disease, cancer and diabetes were not treated in accordance with the CAP guidelines, which recommend combination antibiotic therapy or respiratory fluoroquinolones.
“While certain aspects of the guidelines need to be updated, some prescribers also have room for improvement and should implement the current guidelines,” he said in the release.
Reference:
McKinnell J, et al. Abstract 8450. Presented at: American Thoracic Society International Conference; May 19-24, 2017; Washington, D.C.
Disclosure: McKinnell has served as a research consultant for Achaogen, Allergan, Cempra, Science 37, Theravance and Thermo Fisher. He is a promotional speaker for Allergan and Thermofisher. The study was funded by Cempra; however, McKinnell reports that the opinions and interpretation of the data represent the views of the authors.