Treating Community-Acquired Pneumonia in Hospitalized Patients: Is Combination Tx Beneficial?
the MPR take:
There are varying opinions across international medical societies as to whether hospitalized patients with community-acquired pneumonia require the addition of a macrolide to their β-lactam regimen or if fluoroquinolone monotherapy should be used to cover atypical pathogens, with some suggesting combination therapy should be reserved only for the very ill. A randomized open label study in JAMA Internal Medicine assigned patients ≥18 years with at least two clinical findings suggestive of pneumonia and the presence of a new infiltrate on chest radiograph to either β-lactam alone (monotherapy) or a β-lactam and a macrolide (combination arm). The β-lactam could be cefuroxime (1.5g, 3 times/day intravenously) or amoxicillin and clavulanic acid (1.2g intravenously, 4 times/day); the macrolide was clarithromycin 500mg twice a day intravenously or orally. The primary outcome was the proportion of patients who did not reach clinical stability at day 7, with secondary outcomes of 30- and 90-day mortality, transfer to the intensive care unit, length of stay, readmission, recurrence of pneumonia, subsequent introduction of any new antibiotic, and complicated pleural effusion requiring chest tube insertion or thoracic surgery. A total of 580 patients from January 13, 2009 to January 31, 2013 were evaluated in the study. After 7 days of treatment, noninferiority of monotherapy could not be demonstrated with regards to clinical stability but the combination therapy was statistically superior for patients with atypical pathogens and those with more severe pneumonia. More patients in the monotherapy arm were readmitted 30 days post-discharge compared to the combination arm, which may suggest superiority of the combination arm. Future research on adjusting treatment based on the severity of the pneumonia, with combination therapy for only the most severe of cases, could be beneficial.
Importance: The clinical benefit of adding a macrolide to a -lactam for empirical treatment of moderately severe community-acquired pneumonia remains controversial. Design, Setting, and Participants: Open-label, multicenter, noninferiority, randomized trial conducted from January 13, 2009, through ...
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