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Antipseudomonal monotherapy or combination therapy for older adults with community-onset pneumonia and multidrug-resistant risk factors: a retrospective cohort study

  • Obiageri O. Obodozie-Ofoegbu
    Affiliations
    Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, TX

    Pharmacotherapy Education and Research Center, Long School of Medicine, The University of Texas Health San Antonio, San Antonio, TX
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  • Chengwen Teng
    Affiliations
    Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, TX

    Pharmacotherapy Education and Research Center, Long School of Medicine, The University of Texas Health San Antonio, San Antonio, TX
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  • Eric M. Mortensen
    Affiliations
    Division of Pulmonary and Critical Care Medicine, University of Connecticut School of Medicine, Farmington, CT
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  • Christopher R. Frei
    Correspondence
    Address correspondence to Christopher R. Frei, PharmD, FCCP, BCPS, Director, Pharmacotherapy Education and Research Center, Long School of Medicine, The University of Texas Health San Antonio, 7703 Floyd Curl Dr, MSC-6220, San Antonio, TX 78229.
    Affiliations
    Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, TX

    Pharmacotherapy Education and Research Center, Long School of Medicine, The University of Texas Health San Antonio, San Antonio, TX

    South Texas Veterans Health Care System, San Antonio, TX
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Published:March 21, 2019DOI:https://doi.org/10.1016/j.ajic.2019.02.018

      Highlights

      • This study was a retrospective cohort study of patients with community-onset pneumonia.
      • Antipseudomonal combination therapy has a higher mortality rate than monotherapy.
      • Antipseudomonal combination therapy should not be routinely offered to all patients.

      Background

      Infectious Diseases Society of America guidelines recommend empiric antipseudomonal combination therapy when Pseudomonas is suspected. However, combination antipseudomonal therapy is controversial. This study compares all-cause 30-day mortality in older patients who received antipseudomonal monotherapy (PMT) or antipseudomonal combination therapy (PCT) for the treatment of community-onset pneumonia.

      Methods

      This population-based, retrospective cohort study used data from over 150 Veterans Health Administration hospitals. Patients were classified as being at low, medium, or high risk of drug-resistant pathogens. In total, 31,027 patients were assigned to PCT or PMT treatment arms based on antibiotics received in the first 48 hours of hospital admission.

      Results

      The unadjusted 30-day mortality difference between PCT and PMT was most pronounced in the low-risk group (18% vs 8%), followed by the medium-risk group (24% vs 18%) and then the high-risk group (39% vs 33%). PCT was associated with higher 30-day mortality than PMT overall (adjusted odds ratio [aOR], 1.54; 95% confidence interval [CI], 1.43-1.66) in all 3 risk groups: low (aOR, 1.69; 95% CI, 1.50-1.89), medium (aOR, 1.30; 95% CI, 1.14-1.48), and high (aOR, 1.21; 95% CI, 1.04-1.40).

      Conclusions

      Older adults who received combination antipseudomonal therapy for community-onset pneumonia fared worse than those who received monotherapy. Empiric combination antipseudomonal therapy should not be routinely offered to all patients suspected of having pseudomonal pneumonia.

      Key Words

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