Community-acquired pneumonia in adult outpatients: treatment with antibiotics

Lower respiratory tract infection ( LRTI ) is the third leading cause of death worldwide and the first leading cause of death in low-income countries. Community-acquired pneumonia ( CAP ) is a common condition that causes a significant disease burden for the community, particularly in children younger than five years, the elderly and immunocompromised people.
Antibiotics are the standard treatment for community-acquired pneumonia. However, increasing antibiotic use is associated with the development of bacterial resistance and side effects for the patient.
Several studies have been published regarding optimal antibiotic treatment for community-acquired pneumonia but many of these data address treatments in hospitalised patients.

This is an update of our 2009 Cochrane Review and addresses antibiotic therapies for community-acquired pneumonia in outpatient settings.

Researchers have compared the efficacy and safety of different antibiotic treatments for community-acquired pneumonia in participants older than 12 years treated in outpatient settings with respect to clinical, radiological and bacteriological outcomes.
They looked for randomised controlled trials ( RCTs ), fully published in peer-reviewed journals, of antibiotics versus placebo as well as antibiotics versus another antibiotic for the treatment of community-acquired pneumonia in outpatient settings in participants older than 12 years of age.
However, researchers did not find any studies of antibiotics versus placebo. Therefore, this review includes RCTs of one or more antibiotics, which report the diagnostic criteria and describe the clinical outcomes considered for inclusion in this review.

11 RCTs in this review update ( 3352 participants older than 12 years with a diagnosis of community-acquired pneumonia ) were included; 10 RCTs assessed nine antibiotic pairs ( 3321 participants ) and one RCT assessed four antibiotics ( 31 participants ) in people with community-acquired pneumonia.

The study quality was generally good, with some differences in the extent of the reporting.

A variety of clinical, bacteriological and adverse events were reported. Overall, there was no significant difference in the efficacy of the various antibiotics. Studies evaluating Clarithromycin and Amoxicillin provided only descriptive data regarding the primary outcome.

Though the majority of adverse events were similar between all antibiotics, Nemonoxacin demonstrated higher gastrointestinal and nervous system adverse events when compared to Levofloxacin, while Cethromycin demonstrated significantly more nervous system side effects, especially dysgeusia, when compared to Clarithromycin.
Similarly, high-dose Amoxicillin ( 1 g three times a day ) was associated with higher incidence of gastritis and diarrhoea compared to Clarithromycin, Azithromycin and Levofloxacin.

In conclusion, available evidence from recent RCTs is insufficient to make new evidence-based recommendations for the choice of antibiotic to be used for the treatment of community-acquired pneumonia in outpatient settings.
Pooling of study data was limited by the very low number of studies assessing the same antibiotic pairs.
Individual study results do not reveal significant differences in efficacy between various antibiotics and antibiotic groups.
However, two studies did find significantly more adverse events with use of Cethromycin as compared to Clarithromycin and Nemonoxacin when compared to Levofloxacin.
Multi-drug comparisons using similar administration schedules are needed to provide the evidence necessary for practice recommendations.

Pakhale S et al, Cochrane Database of Systematic Reviews 2014, Issue 10. Art. No.: CD002109. DOI: 10.1002/14651858.CD002109.pub4.


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