As we’ve been repeatedly drilled by our quality groups – and in part to pneumonia core measures – appropriate empiric treatment for hospitalized community-acquired pneumonia is: 1) a beta-lactam plus a macrolide, or 2) respiratory fluoroquinolone monotherapy.
Or is it?
This cluster-randomized trial across seven hospitals in the Netherlands questioned the additive value of the macrolide, in the name of antibiotic resistance, and appear to have come out ahead.
Participants admitted to non-ICU settings with a clinical diagnosis of CAP received either beta-lactam monotherapy, beta-lactam plus macrolide, or respiratory fluoroquinolone monotherapy. With between ~650 and ~890 patients enrolled during the time periods assigned to each arm, the final outcome was: no difference. In fact, across nearly all intention-to-treat, radiographically-confirmed, and strategy-adherent analyses, beta-lactam monotherapy was solidly on the “better than” side of the confidence intervals versus added macrolide therapy. There was no detectable trend with regard to the fluoroquinolone group – excepting the notable advantage of oral administration. Nearly 30% of the fluoroquinolone group received their entire therapy by the oral route alone – an appreciable resource savings, at the least.
The authors do note the low seasonal prevalence of atypical pathogens during the time of the trial. And, as with nearly all topics in medicine, the ultimate conclusion is not an “always” or “never” proposition. However, in the patients selected for this trial, it certainly did not appear harmful to withhold a macrolide when treating with a beta-lactam.
“Antibiotic Treatment Strategies for Community-Acquired Pneumonia in Adults”
http://www.nejm.org/doi/full/10.1056/NEJMoa1406330