JAC Advance Access published online on September 12, 2003
Journal of Antimicrobial Chemotherapy, doi:10.1093/jac/dkg413
© 2003 by The British Society for Antimicrobial Chemotherapy
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Review
1 Division of Medicine,
Department of Acute Medicine and Infectious Diseases, University
Medical Centre Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
* Corresponding author. E-mail: j.j.oosterheert{at}azu.nl.
Background: For years, monotherapy
with a Methods: We systematically reviewed available
studies, retrieved from MEDLINE and by hand-searching reference
lists from recent reviews and guidelines on the effectiveness of
recommended empirical antimicrobial treatment of patients hospitalized
because of CAP. Results: Eight relevant studies were selected.
In six studies significant reductions in mortality were found, in one
study a reduction in hospital length of stay was found and in one
study no beneficial effects could be demonstrated for treatment
regimens with fluoroquinolone monotherapy or combinations of Conclusions: A randomized controlled trial is
warranted to circumvent the methodological flaws in the designs
of the currently available studies. Since the addition of macrolides
or treatment with fluoroquinolones may lead to enhanced antibiotic
resistance, increased side effects and healthcare-related costs, such
a fundamental change in the treatment of CAP should be based on
valid data.
Keywords: macrolide antibiotics, fluoroquinolones, How good is the evidence for the recommended empirical
antimicrobial treatment of patients hospitalized because of community-acquired pneumonia?
A systematic review
2 Division of Medicine,
Department of Acute Medicine and Infectious Diseases; Eijkman-Winkler Institute for Microbiology,
Infectious Diseases and Inflammation, University
Medical Centre Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
3 Julius Centre for Health Sciences and Primary Care, University
Medical Centre Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
-lactam antibiotic (penicillin,
amoxicillin or second-generation cephalosporin) was recommended
as empirical therapy for patients with community-acquired pneumonia (CAP).
A combination of a -lactam and a macrolide
antibiotic was only recommended for patients with severe CAP needing
intensive care treatment or when atypical pathogens, i.e. Legionella
pneumophila, Mycoplasma pneumoniae and Chlamydia
pneumoniae, were strongly suspected. However, new guidelines recommend
a combination of a -lactam antibiotic
plus a macrolide or monotherapy with a fluoroquinolone for all patients
hospitalized with CAP. We evaluated whether treatment with a -lactam plus macrolide or quinolone
monotherapy is truly superior to -lactam
treatment alone.-lactams and macrolides. The beneficial
value of macrolides or fluoroquinolones might be the result of a
large and mainly unrecognized role of atypical pathogens in the
aetiology of CAP, anti-inflammatory effects of macrolides or resistance
to -lactams of the most important pathogens.
However, the studies supporting the recommended treatment regimen
were designed as non-experimental cohort studies. As a consequence,
the results may have been influenced by confounding by indication.
In addition, the outcomes showed several inconsistencies.-lactam antibiotics, mortality, length
of stay
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