Adding a macrolide to a beta-lactam improves outcomes in patients with moderately severe community-acquired pneumonia, according to a noninferiority trial from Switzerland. In the open-label randomized trial, 580 immunocompetent adults were treated with a beta-lactam and a macrolide or a beta-lactam alone and followed for 90 days. After 7 days of treatment, clinical stability was not reached in 41.2% of the monotherapy group vs 33.6% of the combination group (P = 0.07, although the confidence interval exceeded the predefined noninferiority boundary). Patients infected with an atypical bacteria or with more severe pneumonia (Pneumonia Severity Index category IV) fared better with the combination regimen, whereas those not infected with an atypical pathogen or with lower category pneumonia did as well with monotherapy. There were more 30-day readmissions in the monotherapy arm (7.9% vs 3.1%, P = 0.01). Mortality, ICU admission, complications, length of stay, and recurrence of pneumonia within 90 days did not differ between the two regimens. The authors concluded that beta-lactam monotherapy was not noninferior in patients hospitalized for moderately severe community-acquired pneumonia. Patients infected with atypical pathogens or with more severe pneumonia had delayed clinical stability with monotherapy (JAMA Intern Med, published online Oct. 6, 2014. doi:10.1001/jamainternmed.2014.4887). This is somewhat confusing wording to say that single-drug therapy with a beta-lactam alone was not equivalent to dual-drug therapy with a beta-lactam and a macrolide in sicker patients with pneumonia.

 

This supplement was written by William T. Elliott, MD, FACP, Chair, Formulary Committee, Kaiser Permanente, California Division; Assistant Clinical Professor of Medicine, University of California-San Francisco. In order to reveal any potential bias in this publication, we disclose that Dr. Elliott reports no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study. For questions and comments, please e-mail: neill.kimball@ahcmedia.com