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Comparative Effectiveness of Ceftriaxone in Combination With a Macrolide Compared With Ceftriaxone Alone for Pediatric Patients Hospitalized With Community-acquired Pneumonia

Leyenaar, JoAnna K. MD, MPH*; Shieh, Meng-Shiou PhD; Lagu, Tara MD, MPH*‡§; Pekow, Penelope S. PhD†¶; Lindenauer, Peter K. MD, MSc*‡§

The Pediatric Infectious Disease Journal: April 2014 - Volume 33 - Issue 4 - p 387–392
doi: 10.1097/INF.0000000000000119
Antimicrobial Reports

Background: Guidelines for management of community-acquired pneumonia recommend empiric therapy with a macrolide and beta-lactam when infection with Mycoplasma pneumoniae is a significant consideration. Evidence to support this recommendation is limited. We sought to determine the effectiveness of ceftriaxone alone compared with ceftriaxone combined with a macrolide with respect to length of stay and total hospital costs.

Methods: We conducted a retrospective cohort study of children 1–17 years with pneumonia, using Poisson regression and propensity score analyses to assess associations between antibiotic and length of stay. Multivariable linear regression and propensity score analyses were used to assess log-treatment costs, adjusting for patient and hospital characteristics and initial tests and therapies.

Results: A total of 4701 children received combination therapy and 8892 received ceftriaxone alone. Among children 1–4 years of age, adjusted models revealed no significant difference in length of stay, with significantly higher costs in the combination therapy group [cost ratio: 1.08 (95% confidence interval: 1.05–1.11)]. Among children 5–17 years of age, children receiving combination therapy had a shorter length of stay [relative risk: 0.95 (95% confidence interval: 0.92–0.98)], with no significant difference in costs [cost ratio: 1.01 (95% confidence interval: 0.98–1.04)].

Conclusions: Combination therapy did not appear to benefit preschool children but was associated with higher costs. Among school-aged children, combination therapy was associated with a shorter length of stay without a significant impact on cost. Development of sensitive point-of-care diagnostic tests to identify children with M. pneumoniae infection may allow for more focused prescription of macrolides and enable comparative effectiveness studies of targeted provision of combination therapy.

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From the *Division of Pediatric Hospital Medicine, Department of Pediatrics, Tufts University School of Medicine, Boston; Center for Quality of Care Research, Baystate Medical Center, Springfield; Tufts University School of Medicine, Department of Medicine, Boston; §Division of General Medicine, Baystate Medical Center, Springfield; and School of Public Health and Health Sciences, University of Massachusetts, Amherst, MA.

Accepted for publication September 28, 2013.

This study was supported by the National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant UL1 RR025752. The authors have no funding or conflicts of interest to disclose.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (

Address for correspondence: Dr. JoAnna Leyenaar, Division of Pediatric Hospital Medicine, Department of Pediatrics, Tufts University School of Medicine, 800 Washington Street, Boston, MA 02111. E-mail:

© 2014 by Lippincott Williams & Wilkins, Inc.