Do you put CAP patients at risk in your facility?

New antibiotic can improve compliance

If an elderly patient with community-acquired pneumonia (CAP) came to your ED and left with a prescription for antibiotics, would you expect the patient to take the medication? What if the patient has no transportation to a pharmacy, forgets to take the pills, or stops taking the drug because they are feeling better?

"Sometimes we identify these patients, but it is frustrating," says Lisa Kosits, RN, clinical inservice instructor of the division of education and organizational development at Montefiore Medical Center in Bronx, NY.

The hospital pharmacy cannot fill the prescription, nor can the hospital dispense it, because their pharmacy is not authorized to dispense medications for patients to take home, she says. "Oftentimes, social service can intervene and find a pharmacy that will deliver to their home, but it is a time-consuming process."

A new study reports that Zmax (Pfizer, New London, CT; azithromycin extended release), a newly approved single-dose oral antibiotic, is as effective as a seven-day course of levofloxacin for CAP patients and dramatically improves compliance for patients at risk, according to Daniel M. Jorgensen, MD, MPH, head of Pfizer’s clinical research and development.1 According to Pfizer, the average wholesale cost of Zmax is $41.51 per regimen.

With typical multidose regimens, there is no way to ensure that a patient will be compliant with subsequent doses after being discharged from the ED, says Jorgenson. "With Zmax, patients will be able to take their entire treatment regimen as a single oral dose while under observation in the ED," he says. "This ensures 100% completion of therapy."

Patients are at risk

Often, patients return to the ED with worsening symptoms such as shortness of breath, tachypnea, dyspnea, or hypoxia, because of failure to fill their prescription or follow the treatment regimen, says Kosits.

"This is a wonderful breakthrough in the treatment of CAP," she says. Cost is a factor as well, Kosits says. "If we can administer this single dose to patients in the ED, then we can reduce the number of return visits for lack of compliance," she says. Montefiore’s ED treated 2,147 cases of CAP in 2004, says Kosits.

Since CAP is a potentially serious illness that could result in hospitalization or death if not adequately treated, it is reassuring to know that the patient already received treatment when leaving the ED, especially when adequate follow-up care not always is guaranteed, says Jorgensen.

With multidose regimens, patients may skip or miss doses, share medication with others, save medication for future use, or simply refuse to get the prescription filled, he notes. "Patients who use an ED for their primary care services are more likely to engage in these noncompliance activities than those who use a primary care clinic," Jorgensen adds.

Noncompliance can lead to treatment failure, and when this failure happens, patients tend to visit an ED for subsequent care, regardless of where they were initially diagnosed and treated, adds Jorgensen. "This is especially true for a potentially serious illness, such as CAP," he says. "If not adequately treated, CAP patients could end up in the hospital or could die."

Remind patients who take single-dose Zmax that even though the therapy has been completed, improvement of signs and symptoms may not be immediately apparent on the first day, says Jorgensen.

This is true for all antibiotics; they need time to get to the site of the infection to kill the bacteria, he says. "The difference is that once Zmax begins to work, it continues to work without the need for additional doses, unlike multidose regimens, which must be given every day even after the patient starts feeling better."

It is this time, when the patient starts feeling better, that noncompliance is most likely to occur, says Jorgensen. "That is, patients figure they are already cured and feel there is no need to take additional medication."

With the growing problem of noncompliance and the consequences of treatment failure and drug resistance, it may feel like an uphill battle for ED nurses, he says. "The best possible way to ensure that these patients receive adequate therapy is to administer the entire regimen in the ED in a directly observed fashion," Jorgensen says.


  1. D’Ignazio J, Camere MA, Lewis DE, et al. Novel, single-dose microsphere formulation of azithromycin versus 7 days levofloxacin for the treatment of mild-to-moderate community-acquired pneumonia in adults. Antimicrobial Agents Chemother 2005; 45(10). In press.


For more information on community-acquired pneumonia and antibiotic treatment, contact:

Daniel M. Jorgensen, MD, MPH, Clinical Research and Development, Pfizer, 50 Pequot Ave., New London, CT 06320. Telephone: (860) 732-4709. E-mail:

Lisa Kosits, RN, Clinical Inservice Instructor, Division of Education and Organizational Development, Montefiore Medical Center, 111 E. 210th St., Bronx, NY 10467. Telephone: (718) 920-5241. Fax: (718) 324-4246. E-mail: