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* From the Health Care Financing Administration (Drs. Houck and Lowery, and Mr. MacLehose), Region 10, Seattle, WA; and Winthrop University Hospital (Dr. Niederman), Mineola, NY.
Correspondence to: Peter Houck, MD, HCFA, MS RX-40, 2201 Sixth Ave, Seattle, WA 98121; e-mail: phouck{at}hcfa.gov
Study objectives: To examine the association of empiric inpatient antibiotic treatment of community-acquired pneumonia (CAP) with mortality, and whether this association varies from year to year.
Design: Population-based, retrospective study adjusting for demographics, comorbidities, and clinical characteristics.
Setting: Acute-care hospitals in 10 western states.
Patients: A group of 10,069 Medicare
beneficiaries aged 
65 years who were hospitalized with CAP during
fiscal years 1993, 1995, and 1997.
Measurements and results: We examined the risk for mortality during the 30 days after admission to the hospital. The impact of specific antibiotic regimens varied greatly from year to year. In 1993, therapy with a macrolide plus a ß-lactam was associated with significantly lower mortality than therapy with either a ß-lactam alone (adjusted odds ratio [AOR], 0.42; 95% confidence interval [CI], 0.25 to 0.69) or other regimens that did not include a macrolide, ß-lactam, or fluoroquinolone (AOR, 0.35; 95% CI, 0.20 to 0.62). Those associations were not observed in 1995 or 1997. Lower mortality was associated with fluoroquinolone monotherapy compared with ß-lactam monotherapy in 1997 (AOR, 0.27; 95% CI, 0.07 to 0.96) and with macrolide monotherapy compared with other regimens in 1995 (AOR, 0.24; 95% CI, 0.06 to 0.93), but the number of patients who received these regimens was small.
Conclusions: The inclusion of a macrolide or a fluoroquinolone in initial empiric CAP treatment was associated with improved survival, but this association varied from year to year, perhaps as a result of a temporal variation in the incidence of atypical pathogen pneumonia. Improved testing and surveillance for atypical pathogen pneumonia are needed to guide empiric therapy.
Key Words: atypical pathogen • community-acquired • macrolide • mortality • pneumonia
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