Healthcare News & Insights

Community-acquired pneumonia: Monotherapy works just as well as other approaches

For patients hospitalized with community-acquired pneumonia, but don’t need to be put in the ICU, which antibiotic treatment is best: beta-lactam monotherapy, beta-lactam-macrolide combination therapy or fluoroquinolone monotherapy? 

According to treatment guidelines, it depends on the severity of disease based on level of care needed or prognostic risk score. But most recommendations say either beta-lactam-macrolide combination therapy or fluoroquinolone monotherapy. Problem is, these recommendations have led to increased use of macrolides and fluoroquinolones, both of which are associated with increasing microbial resistance.

Experts say the guidelines are more complicated than they have to be, and there’s little evidence supporting them, so the conservative beta-lactam monotherapy is best.

Who’s right?

A study that was published in The New England Journal of Medicine, compared all three empirical antibiotic treatments strategies and found there was no significant difference in 90-day mortality rates, length of stay and reported complications.

The study rotated treatment strategies in four-month periods from February 2011 through August 2013. Patients 18 years and older with clinically suspected community-acquired pneumonia who required antibiotic treatment and hospitalization in a non-ICU ward were eligible. A total of 2,283 patients, with a mean age of 70, were included. Of those, 656 patients only got the beta-lactam strategy, 739 got beta-lactam-macrolide strategy and 888 got the fluoroquinolone strategy.

The primary outcome was all-cause mortality within 90 days after admission, and secondary outcomes were time starting oral treatment, length of stay and occurrence of minor or major complications during hospitalization.

What researchers found

Investigators found the crude 90-day mortality rate was 9% for beta-lactam monotherapy, 11.1% for beta-lactam-macrolide and 8.8% for fluoroquinolone. These results indicate noninferiority of the beta-lactam strategy, since neither difference exceeded the 3% preset noninferiority margin.

The causes of community-acquired pneumonia were also examined, and they were similar in all three treatment groups with streptococcus pneumoniae being the most frequent followed by Haemophilus influenzae.

Atypical pathogens, which can’t be killed or inhibited by penicillin or other beta-lactam antibiotics, were found in 2.1 % of patients.

The number of patients empirically treated with antibiotic coverage for atypical pathogens during the beta-lactam strategy periods was 67% less than the number treated with atypical coverage during the beta-lactam-macrolide strategy periods and 69% less than the number during the fluoroquinolone strategy periods.

Resistance to the initial antibiotic was highest with the beta-lactam strategy.

Secondary outcomes:

  • Median length of stay was six days for all three strategies
  • Proportions of patients whose treatment started with oral antibiotics were 27% during fluoroquinolone strategy periods, compared with 13% during beta-lactam strategy periods and 10% during beta-lactam-macrolide strategy periods
  • Median duration of intravenous treatment was three days during the fluoroquinolone strategy periods and four days for the other two treatment strategies, and
  • There was no significant difference among the three strategies in incidence of major or minor complication.

Unique study

This study is unique because it looked at treatment strategies instead of specific antibiotics.

With the overuse of antibiotics, and increasing resistance to fluoroquinolones and macrolides, it’s good to know you can now treat your hospitalized non-ICU community-acquired pneumonia patients with beta-lactam monotherapy, instead of the broader-spectrum antimicrobial treatment regimens recommended in the current guidelines, without compromising patient outcomes.







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