Clinical Question:
In adults admitted for treatment of community-acquired pneumonia, is an
antibiotic for atypical organisms more effective than beta-lactam-only
treatment?
Bottom Line:
Empirical antibiotic coverage of atypical pathogens in hospitalized patients
with community-acquired pneumonia showed no benefit of survival or clinical
efficacy in this synthesis of randomized trials.
Reference:
Empirical atypical coverage for inpatients with community-acquired
pneumonia: systematic review of randomized controlled trials.Shefet D,
Robenshtok E, Paul M, Leibovici L. Arch Intern Med. 2005 Sep
26;165(17):1992-2000.
Study Design:
Meta-analysis (randomized controlled trials)
Funding:
Foundation
Setting:
Inpatient (any location)
Synopsis:
Current guidelines of empirical antibiotic treatment for inpatients with
community-acquired pneumonia recommend antibiotics whose spectrum covers
intracellular (atypical) pathogens. No sufficient evidence exists to support
the necessity of such coverage, whereas limiting it may reduce toxic
effects, resistance, and expense. Our goal was to assess the efficacy of
empirical coverage of atypical pathogens in terms of mortality and clinical
and bacteriological success. Systematic review and meta-analysis of
randomized, controlled trials comparing treatment regimens with and without
coverage of atypical pathogens. We searched MEDLINE, EMBASE, the Cochrane
Library, and references. Relative risks (RRs) with 95% confidence intervals
(CIs) were pooled using the fixed-effects model. The primary outcome
assessed was all-cause mortality. We included 24 trials encompassing 5015
patients. We found no studies of a drug without atypical coverage that
compared it with the same drug supplemented with a drug with atypical
coverage; nearly all compared a beta-lactam with a single quinolone or
macrolide. There was no difference in mortality between the 2 arms (RR, 1.13
[95% CI, 0.82-1.54]). Regimens with coverage of atypical pathogens showed a
trend toward clinical success and a significant advantage to bacteriological
eradication. Both disappeared when evaluating methodologically high-quality
studies alone. These regimens further showed a significant advantage in
clinical success for Legionella pneumophila, whereas no advantage for
pneumococcal pneumonia was seen. There was no difference between study arms
in the frequency of total adverse events. |