Comparing Antibiotic Treatment Options for CAP

Guidelines recommend using either monotherapy with a fluoroquinolone or combination therapy with a β-lactam plus a macrolide or a fluoroquinolone as empirical treatment for patients with suspected community-acquired pneumonia (CAP) who require hospitalization but not intensive care unit (ICU) admission. However, the data supporting these recommendations are not robust. Now, in a pragmatic, cluster-randomized, crossover trial involving adults with suspected CAP hospitalized on non-ICU wards, investigators in the Netherlands have compared β-lactam monotherapy, fluoroquinolone monotherapy, and β-lactam–macrolide combination therapy with respect to 90-day mortality.

Between February 2011 and August 2013, 2283 patients at seven hospitals were enrolled. A microbial etiology was determined in only a minority of them, with Streptococcus pneumoniae (15.9%) and Haemophilus influenzae (5.8%) most commonly identified, and “atypical” pathogens found in only 2.1%. Noninferiority analyses showed no significant difference in 90-day mortality rates — crude or adjusted — among the three regimens in the intent-to-treat or antibiotic-adherent populations. There were also no clinically relevant differences in hospital length of stay or rates of major or minor complications. The shift from intravenous to oral antibiotic therapy occurred earlier with fluoroquinolone monotherapy than with either of the other two regimens (median, 3 vs. 4 days).