Monotherapy or combined antibiotic therapy in the treatment of community acquired pneumonia
Date First Published:
January 18, 2007
Last Updated:
February 1, 2007
Report by:
Kirsty Luescher, F2 (Manchester Royal Infirmary)
Three-Part Question:
In [patients with community acquired pneumonia] are [macrolides combined with beta-lactams better than beta-lactams alone] [in inproving outcome and hastening recovery]
Clinical Scenario:
A 65 year old man presents to the A&E department with shortness of breath and cough productive of green sputum. There is radiological evidence of pneumonia on chest x-ray and oral amoxicillin is started. You wonder whether adding in a macrolide would benefit the patient.
Search Strategy:
Medline 1966-06/12 using the PubMed interface
The Cochrane Library
The Cochrane Library
Search Details:
[therapy OR therapeutics OR therapeutics OR treatment] AND [residence characteristics OR community] AND [acquired] AND [pneumonia OR pneumonia] AND [beta-lactams OR beta-lactam] AND [macrolide]. LIMIT to English language
Outcome:
Altogether 97 papers were found in Medline and 0 in The Cochrane Library. A total of 4 papers were relevent to the above clinical question.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Impact of initial antibiotic choice on mortality from pneumococcal pneumonia. Aspa J, Rajas O, Rodriguez de Castro F, Huertas MC, Borderias L, Cabello FJ, Tabara J, Hernandez-Flix S, Martinez-Sanchis A, Torres A; The Pneumococcal Pneumonia in Spain Study Group 2006 Spain | 638 patients with community-acquired pneumonia due to Streptococcus pneumoniae. Patients were grouped into the following categories: beta-lactam monotherapy (n = 251), macrolide monotherapy (n = 37), beta-lactam plus macrolide (n = 198), levofloxacin alone/combination (n = 48), and other combinations (n = 104). The antibiotic regimen was chosen by the attending physician. |
Prospective observational study | 30 day mortality | No significant difference | Antibiotic therapy was assigned to patients subjectively by the physician. |
| Empiric Antibiotic Therapy and Mortality Among Medicare Pneumonia. Inpatients in 10 Western States : 1993, 1995, and 1997 Peter M. Houck, Richard F. MacLehose, Michael S. Niederman and Joseph K. Lowery 2001 America | Six antibiotic regimens were initiated during the first 24 h after arrival at hospital were evaluated: monotherapy with a b-lactam; macrolide monotherapy; therapy with a b-lactam plus a macrolide; fluoroquinolone monotherapy; therapy with a b-lactam plus a fluoroquinolone; and any other antibiotics. |
Population-based, retrospective study. | 30 day mortality rate | 1993 Mortality B-lactam monotherapy - 13.9% B-lactam and macrolide combined - 8.3%(CI 0.25-0.69, P0.001) 1995 Mortality B-lactam monotherapy - 11.8% B-lactam and macrolide combined - 8.6%(CI 0.62–1.41, p=0.746) 1997 Mortality B-lactam monotherapy - 13.9% B-lactam and Macrolide combined - 10.2%(CI 0.63–1.19 p=0.375) | 39.9% of patients origionally inclused in the study were excluded due to problems with data collection. |
| Impact of Initial Antibiotic Choice on Clinical Outcomes in Community-Acquired Pneumonia: Analysis of a Hospital Claims-Made Database Richard B. Brown, Paul Iannini, Peter Gross and Mark Kunkel 2003 America | 44,814 patients over the age of 18 with a diagnosis of community acquired pneumonia were divided into treatment cohorts based on individual antiobiotic therapy: Monotherapy - (1) ceftriaxone, (2) macroides, (3) other cephalosporins, (4) fluorinated quinolones, (5) penicillins. Dual therapy - the four classes above(except macrolides) plus a macrolide as the second agent. |
Retrospective cohort study. | Impact of initial antibiotic choice on 30 day mortality, total hospital costs and hospital length of stay. | Mean length of hospital stay: B-lactam monotherapy 6.09days(4.25SD). B-Lactam and macolide combined 6.08days(3.82SD) Overall p value - 0.0867. Overall mortality: B-lactam monotherapy 8.15%, B-Lactam and macolide combined 2.46% Overall p vaue less than 0.0001 | Over 60% of patients had incomplete antibiotic treatment information, and therefore no treatment characterisation was possible. |
| Lower mortality among patients with community-acquired pneumonia treated with a macrolide plus a beta-lactam agent versus a beta-lactam agent alone. Garcia Vazquez E, Mensa J, Martinez JA, Marcos MA, Puig J, Ortega M, Torres A. 2005 Spain | A cohort of 1,391 patients with community-acquired pneumonia of unknown etiology, atypical pneumonia, Legionella pneumophila pneumonia, viral pneumonia, or pneumococcal pneumonia was studied according to a standard protocol to analyse whether the addition of a macrolide to beta-lactam empirical treatment decreases mortality rates. | Cohort study | 30 day mortality | Mortality rate: B-Lactam monotherapy - 13.3% Mortality rate: B-Lactam and macrolide combined - 6.9% (p=0.001). | An etiological diagnosis was not achieved in 64.2% of patients and therefore it could not be determined if the patients had typical or atypical infection. |
Author Commentary:
There is good evidence available that combining a B-Lactam antiobiotic with a macrolide improves the clinical outcome of community acquired pneumonia. More research is required into whether the addition of a macroide would continue to be beneficial in patients with suspected uncomplicated, typical infection.
Bottom Line:
In patients who present to hospital with community acquired pneumonia the addition of a macrolide should always be considered. Side effects, complications and cost effectiveness of additional antibiotic therapy must always be taken into consideration.
References:
- Aspa J, Rajas O, Rodriguez de Castro F, Huertas MC, Borderias L, Cabello FJ, Tabara J, Hernandez-Flix S, Martinez-Sanchis A, Torres A; The Pneumococcal Pneumonia in Spain Study Group. Impact of initial antibiotic choice on mortality from pneumococcal pneumonia.
- Peter M. Houck, Richard F. MacLehose, Michael S. Niederman and Joseph K. Lowery. Empiric Antibiotic Therapy and Mortality Among Medicare Pneumonia. Inpatients in 10 Western States : 1993, 1995, and 1997
- Richard B. Brown, Paul Iannini, Peter Gross and Mark Kunkel. Impact of Initial Antibiotic Choice on Clinical Outcomes in Community-Acquired Pneumonia: Analysis of a Hospital Claims-Made Database
- Garcia Vazquez E, Mensa J, Martinez JA, Marcos MA, Puig J, Ortega M, Torres A.. Lower mortality among patients with community-acquired pneumonia treated with a macrolide plus a beta-lactam agent versus a beta-lactam agent alone.