Respiratory fluoroquinolones for the treatment of community-acquired pneumonia: a meta-analysis of randomized controlled trials

Abstract

CMAJ ResearchBackground: We investigated whether the use of respiratory fluoroquinolones was associated with better clinical outcomes compared with the use of macrolides and β-lactams among adults with pneumonia. Methods:We searched PubMed, Current Contents, Scopus, EMBASE, ClinicalTrials.gov and Cochrane with no language restrictions. Two reviewers independently extracted data from published trials that compared fluoroquinolones (levofloxacin, moxifloxacin, gemifloxacin) with macrolides or β-lactams or both. A meta-analysis was performed with the clinical outcomes of mortality, treatment success and adverse outcomes. Results:We included 23 trials in our meta-analysis. There was no difference in mortality among patients who received fluoroquinolones or the comparator antibiotics (OR 0.85, 95% CI 0.65-1.12). Pneumonia resolved in more patients who received fluoroquinolones compared with the comparator antibiotics for the included outcomes in the intention-to-treat population (OR 1.17, 95% CI 1.00-1.36), clinically evaluable population (OR 1.26, 95% CI 1.06-1.50) and the microbiologically assessed population (OR 1.67, 95% CI 1.28-2.20). Fluoroquinolones were more effective than a combination of β-lactam and macrolide (OR 1.39, 95% CI 1.02-1.90). They were also more effective for patients with severe pneumonia (OR 1.84, 95% CI 1.02-3.29), those who required admission to hospital (OR = 1.30, 95% CI 1.04-1.61) and those who required intravenous therapy (OR = 1.44, 15% CI 1.13-1.85). Fluoroquinolones were more effective than β-lactam and macrolide in open-label trials (OR = 1.35, 95% CI 1.08-1.69) but not in blinded randomized controlled trials (OR = 1.13, 95% CI 0.85-1.50).Interpretation: Fluoroquinolones were associated with higher success of treatment for severe forms of pneumonia; however, a benefit in mortality was not evident. A randomized controlled trial that includes patients with severe pneumonia with or without bacteremia is needed.

Study conclusions should reflect results

“…1 The correct conclusion from their data should be that fluoroquinolones are no better than comparator antibiotics in the treatment of community-acquired pneumonia. A secondary conclusion should be that, in blinded and highquality studies, there is no difference in mortality rate or treatment success for patients who receive fluoroquinolones versus comparator antibiotics.…”

Study conclusions should reflect results

“…1 We chose mortality as our primary outcome because of the considerable mortality rate attributed to community-acquired pneumonia in several previous studies. However, the mortality rate for patients with pneumonia in several of the randomized controlled trials included in our meta-analysis was extremely low, and the mortality rate for patients in the subgroups with severe or bacteremic pneumonia was not reported.…”

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

“…A study done by Querol-Ribelles et al stated that the median LOS for levofloxacin was 5 days, while the median LOS for ceftriaxone-clarithromycin was 6 days, but no significant difference was found [17]. According to a meta-analysis conducted by Vardakas et al, the LOS for patients who received fluoroquinolone was 1-2 days shorter than patients who received antibiotics of macrolide or beta-lactam or a combination of both [18].…”