Clinical question: What is the best antibiotic strategy to improve outcomes in patients hospitalized with community-acquired pneumonia?
Bottom line: For patients hospitalized with community-acquired pneumonia (CAP), start antibiotics early, use either fluoroquinolone monotherapy or beta-lactam/macrolide combination therapy, and switch to oral antibiotics as soon as patients are hemodynamically stable and can take oral medications. Although the evidence is mostly of low quality, this review reaffirms what we already do. (LOE = 2a)
Reference: Lee JS, Giesler DL, Gellad WF, Fine MJ. Antibiotic therapy for adults hospitalized with community-acquired pneumonia. JAMA 2016;315(6):593-602.
Study design: Systematic review
Funding source: Unknown/not stated
Allocation: Uncertain
Setting: Inpatient (ward only)
Synopsis: These investigators searched MEDLINE, EMBASE, and the Cochrane databases to identify studies that evaluated outcomes for patients hospitalized with CAP with regard to optimal timing of antibiotic initiation, initial antibiotic selection, and criteria for transition from intravenous to oral antibiotic therapy. Two authors independently reviewed studies for inclusion and assessed study quality.
Of 8 low-quality observational studies, 4 showed a significant association between initiating antibiotic therapy within 4 hours to 8 hours of hospital arrival and reduced mortality. When comparing 2 different antibiotic strategies, 6 of 8 observational studies showed mortality benefit with the use of beta-lactams plus macrolides as compared with beta-lactam monotherapy, though the 2 recent high-quality randomized trials had conflicting results. All three observational studies that compared fluoroquinolones with beta-lactam monotherapy for the treatment of CAP showed an association with fluoroquinolone use and decreased mortality.
Finally, one high-quality trial showed that transitioning patients to oral antibiotics once they meet clinical criteria for stability (stable vital signs, lack of confusion, ability to tolerate oral medications) leads to a shorter length of stay.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.