Macrolides vs. quinolones for community-acquired pneumonia: meta-analysis of randomized controlled trials

Abstract

The relative efficacy, safety and ecological implications of macrolides vs. quinolones in the treatment of community-acquired pneumonia (CAP) are debatable. We performed a systematic review and meta-analysis of randomized controlled trials comparing any macrolide vs. any quinolone for the treatment of CAP among adult inpatients or outpatients, as monotherapy or both in combination with a beta-lactam. We did not limit inclusion by pneumonia severity, publication status, language or date of publication. The primary outcomes assessed were 30-day all-cause mortality and treatment failure. Two authors independently extracted the data. Fixed effect meta-analysis of risk ratios (RRs) with 95% confidence intervals was performed. Sixteen trials (4989 patients) fulfilling inclusion criteria were identified, mostly assessing outpatients with mild to moderate CAP. All-cause mortality was not significantly different for macrolides vs. quinolones, RR 1.03 (0.63-1.68, seven trials), with a low event rate (2%). Treatment failure was significantly lower with quinolones, RR 0.78 (0.67-0.91, 16 trials). The definition of failure used in the primary studies was not clearly representative of patients' benefit. Microbiological failure was lower with quinolones, RR 0.63 (0.49-0.81, 13 trials). All adverse events, adverse events requiring discontinuation and any premature antibiotic discontinuation were significantly more frequent with macrolides, mainly on account of gastrointestinal adverse events. Resistance development was not assessed in the trials. Randomized controlled trials show an advantage of quinolones in the treatment of CAP with regard to clinical cure without need for antibiotic modification at end of treatment and gastrointestinal adverse events. The clinical significance of this advantage is unclear.

Cost-Effectiveness Analysis of Ceftriaxone-Azithromycin Combination and Single Levofloxacin as Empirical Antibiotics in Community-Acquired Pneumonia Inpatients at Persahabatan Hospital

“…A study by Garau et al also found a significant relationship between LOS and death as well as LOS and PSI score (especially in Classes IV and V PSI, positive blood culture, ICU admission, and alcohol consumption) in patients with CAP [20]. The results of the current study are in agreement with the two previous studies, as the current study found a significant relationship between LOS and PSI score (degree of severity) [14].…”

“…A meta-analysis done by Skalsky et al stated that there is no significant difference in the mortality rate between quinolone groups and monotherapy macrolide or combination with beta-lactam RR (1.03. 95%, CI: 0.63-1.68) [14].…”

A review of macrolide based regiments for community-acquired pneumonia.

“…The first was in 2012 and reviewed 12 out-patient, and four in-patient studies from 1993 to 2005. 39 Most patients had mild to moderate CAP. Each study that was reviewed compared regimens that included a fluoroquinolone to regimens that included a macrolide.…”

Pneumonia as an actual medical problem of the 21th century

“…В исследовании K.Skalsky et al [22] составлен си стемный обзор и проведен метаанализ по оценке эффективности макролидов и хинолонов в группе пациентов с приобретенной пневмонией. В суще ствующих клинических рекомендациях АБП 1 й линии считаются макролиды; в Великобритании предпочтение отдается АБП пенициллинового ряда и макролидам.…”