{'fraction_non_alphanumeric': 0.03207470564352416, 'fraction_numerical': 0.010556232237109216, 'mean_word_length': 5.65945945945946, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Comment: Cost-Effectiveness of Macrolides in Lower Respiratory Tract Infections

TO THE EDITOR:In their letter on the cost-effectiveness of macrolides (1999;33:1125-6), Dietrich et al. suggested that “azithromycin was identified as the most cost-effective treatment regimen” (when compared with roxithromycin and clarithromycin). From the perspective of a pulmonologist and pharmacoeconomist, we believe that this statement is unfounded by the evidence presented in that letter. The authors neglected to provide evidence that the diseases evaluated (pneumonia, bronchitis) are comparable between treatment regimens. A diagnosis of pneumonia or bronchitis represents a heterogeneous population with a broad spectrum of underlying lung pathology and different responses to therapy. The authors did not document assessment of the patients to determine the severity of pneumonia or type of bronchitis (acute, chronic, or acute exacerbation of chronic). In addition to published accounts of randomized clinical trials, Dietrich et al. included undisclosed trial data from manufacturers’ databases, which, based on the evidence provided (or not provided), could bias the analysis. We believe the authors’ claim that “Azithromycin clearly dominated over clarithromycin and roxithromycin because it was more effective than roxithromycin and showed fewer adverse effects than clarithromycin” is misleading. Dietrich et al. did not provide statistical assessment of the pooled microbiologic success rates or treatment success rates. Our statistical analysis using the two-tailed Fisher’s exact test showed that there was no advantage of azithromycin versus clarithromycin for microbiologic success (p = 0.25). Our analysis of therapeutic success showed an advantage of azithromycin versus clarithromycin for patients with pneumonia (p = 0.004), but no advantage for patients with bronchitis (p = 0.72) or pneumonia plus bronchitis (p = 0.51), which accounted for approximately 80% of the cases evaluated. Dietrich et al. also claimed that clarithromycin “is still the least economically favorable treatment throughout the different evaluations performed....” However, the authors failed to provide data to substantiate this claim, presumably based on the results of sensitivity analysis and expenses incurred for adverse effects. We believe that more rigorous and forthcoming economic analyses are required before such cost-effectiveness superiority claims are justifiable.