Comparison of Clarithromycin and Amoxicillin/Clavulanic Acid for Community-Acquired Pneumonia in an Era of Drug-Resistant Streptococcus pneumoniae

Identifying the Best Initial Oral Antibiotics for Adults with Community-Acquired Pneumonia: A Network Meta-Analysis

BACKGROUND

The objective of this network meta-analysis was to compare rates of clinical response and mortality for empiric oral antibiotic regimens in adults with mild-moderate community-acquired pneumonia (CAP).

METHODS

We searched PubMed, Cochrane, and the reference lists of systematic reviews and clinical guidelines. We included randomized trials of adults with radiologically confirmed mild to moderate CAP initially treated orally and reporting clinical cure or mortality. Abstracts and studies were reviewed in parallel for inclusion in the analysis and for data abstraction. We performed separate analyses by antibiotic medications and antibiotic classes and present the results through network diagrams and forest plots sorted by p-scores. We assessed the quality of each study using the Cochrane Risk of Bias framework, as well as global and local inconsistency.

RESULTS

We identified 24 studies with 9361 patients: six at low risk of bias, six at unclear risk, and 12 at high risk. Nemonoxacin, levofloxacin, and telithromycin were most likely to achieve clinical response (p-score 0.79, 0.71, and 0.69 respectively), while penicillin and amoxicillin were least likely to achieve clinical response. Levofloxacin, nemonoxacin, azithromycin, and amoxicillin-clavulanate were most likely to be associated with lower mortality (p-score 0.85, 0.75, 0.74, and 0.68 respectively). By antibiotic class, quinolones and macrolides were most effective for clinical response (0.71 and 0.70 respectively), with amoxicillin-clavulanate plus macrolides and beta-lactams being less effective (p-score 0.11 and 0.22). Quinolones were most likely to be associated with lower mortality (0.63). All confidence intervals were broad and partially overlapping.

CONCLUSION

We observed trends toward a better clinical response and lower mortality for quinolones as empiric antibiotics for CAP, but found no conclusive evidence of any antibiotic being clearly more effective than another. More trials are needed to inform guideline recommendations on the most effective antibiotic regimens for outpatients with mild to moderate CAP.

Guía de práctica clínica para el manejo de la neumonía adquirida en la comunidad

La neumonía sigue siendo una de las principales causas de consulta y de hospitalización a la que, además de su un alto impacto en términos de morbilidad y mortalidad, se suma la actual problemática de resistencia a los antimicrobianos, por lo que establecer directrices que permitan su adecuado diagnóstico y tratamiento es de gran importancia para obtener mejores desenlaces clínicos y promover un uso racional de antibióticos en estos pacientes. La presente guía de práctica clínica (GPC) contiene recomendaciones basadas en la evidencia para el diagnóstico y tratamiento de la neumonía adquirida en la comunidad en adultos, las cuales fueron realizadas mediante el proceso de adaptación de GPC basadas en la evidencia para el contexto colombiano.

Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America

Background: This document provides evidence-based clinical practice guidelines on the management of adult patients with community-acquired pneumonia.

Methods: A multidisciplinary panel conducted pragmatic systematic reviews of the relevant research and applied Grading of Recommendations, Assessment, Development, and Evaluation methodology for clinical recommendations.

Results: The panel addressed 16 specific areas for recommendations spanning questions of diagnostic testing, determination of site of care, selection of initial empiric antibiotic therapy, and subsequent management decisions. Although some recommendations remain unchanged from the 2007 guideline, the availability of results from new therapeutic trials and epidemiological investigations led to revised recommendations for empiric treatment strategies and additional management decisions.

Conclusions: The panel formulated and provided the rationale for recommendations on selected diagnostic and treatment strategies for adult patients with community-acquired pneumonia.

Antibiotics for community-acquired pneumonia in adult outpatients

BACKGROUND

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 CAP. 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 CAP but many of these data address treatments in hospitalised patients. This is an update of our 2009 Cochrane Review and addresses antibiotic therapies for CAP in outpatient settings.

OBJECTIVES

To compare the efficacy and safety of different antibiotic treatments for CAP in participants older than 12 years treated in outpatient settings with respect to clinical, radiological and bacteriological outcomes.

SEARCH METHODS

We searched CENTRAL (2014, Issue 1), MEDLINE (January 1966 to March week 3, 2014), EMBASE (January 1974 to March 2014), CINAHL (2009 to March 2014), Web of Science (2009 to March 2014) and LILACS (2009 to March 2014).

SELECTION CRITERIA

We 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 CAP in outpatient settings in participants older than 12 years of age. However, we 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.

DATA COLLECTION AND ANALYSIS

Two review authors (LMB, TJMV) independently assessed study reports in the first publication. In the 2009 update, LMB performed study selection, which was checked by TJMV and MMK. In this 2014 update, two review authors (SP, SM) independently performed and checked study selection. We contacted trial authors to resolve any ambiguities in the study reports. We compiled and analysed the data. We resolved differences between review authors by discussion and consensus.

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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 CAP 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. Further studies focusing on diagnosis, management, cost-effectiveness and misuse of antibiotics in CAP and LRTI are warranted in high-, middle- and low-income countries.

Antibiotics for community-acquired pneumonia in children

BACKGROUND

Pneumonia caused by bacterial pathogens is the leading cause of mortality in children in low-income countries. Early administration of antibiotics improves outcomes.

OBJECTIVES

To identify effective antibiotic drug therapies for community-acquired pneumonia (CAP) of varying severity in children by comparing various antibiotics.

SEARCH METHODS

We searched CENTRAL 2012, Issue 10; MEDLINE (1966 to October week 4, 2012); EMBASE (1990 to November 2012); CINAHL (2009 to November 2012); Web of Science (2009 to November 2012) and LILACS (2009 to November 2012).

SELECTION CRITERIA

Randomised controlled trials (RCTs) in children of either sex, comparing at least two antibiotics for CAP within hospital or ambulatory (outpatient) settings.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data from the full articles of selected studies.

MAIN RESULTS

We included 29 trials, which enrolled 14,188 children, comparing multiple antibiotics. None compared antibiotics with placebo.Assessment of quality of study revealed that 5 out of 29 studies were double-blind and allocation concealment was adequate. Another 12 studies were unblinded but had adequate allocation concealment, classifying them as good quality studies. There was more than one study comparing co-trimoxazole with amoxycillin, oral amoxycillin with injectable penicillin/ampicillin and chloramphenicol with ampicillin/penicillin and studies were of good quality, suggesting the evidence for these comparisons was of high quality compared to other comparisons.In ambulatory settings, for treatment of World Health Organization (WHO) defined non-severe CAP, amoxycillin compared with co-trimoxazole had similar failure rates (odds ratio (OR) 1.18, 95% confidence interval (CI) 0.91 to 1.51) and cure rates (OR 1.03, 95% CI 0.56 to 1.89). Three studies involved 3952 children.In children with severe pneumonia without hypoxaemia, oral antibiotics (amoxycillin/co-trimoxazole) compared with injectable penicillin had similar failure rates (OR 0.84, 95% CI 0.56 to 1.24), hospitalisation rates (OR 1.13, 95% CI 0.38 to 3.34) and relapse rates (OR 1.28, 95% CI 0.34 to 4.82). Six studies involved 4331 children below 18 years of age.In very severe CAP, death rates were higher in children receiving chloramphenicol compared to those receiving penicillin/ampicillin plus gentamicin (OR 1.25, 95% CI 0.76 to 2.07). One study involved 1116 children.

AUTHORS' CONCLUSIONS

For treatment of patients with CAP in ambulatory settings, amoxycillin is an alternative to co-trimoxazole. With limited data on other antibiotics, co-amoxyclavulanic acid and cefpodoxime may be alternative second-line drugs. Children with severe pneumonia without hypoxaemia can be treated with oral amoxycillin in an ambulatory setting. For children hospitalised with severe and very severe CAP, penicillin/ampicillin plus gentamycin is superior to chloramphenicol. The other alternative drugs for such patients are co-amoxyclavulanic acid and cefuroxime. Until more studies are available, these can be used as second-line therapies.There is a need for more studies with radiographically confirmed pneumonia in larger patient populations and similar methodologies to compare newer antibiotics. Recommendations in this review are applicable to countries with high case fatalities due to pneumonia in children without underlying morbidities and where point of care tests for identification of aetiological agents for pneumonia are not available.

Safety and tolerability of commonly prescribed oral antibiotics for the treatment of respiratory tract infections

Recent data suggest that adverse events (AEs) associated with the use of antimicrobial drugs are a major safety concern, with antibiotics implicated in a significant proportion (approximately 20%) of all drug-related emergency department visits in the United States. Although most of these visits are attributable to allergic reactions (79%), certain commonly prescribed antibiotics are notable contributors to conditions that range in nature from gastrointestinal to neurologic and/or psychiatric--particularly after ED visits are adjusted per outpatient prescription visits. This article reviews medically significant AEs of agents included in the major antimicrobial classes--AEs that may be underappreciated by general practitioners. Considerable attention is devoted to the fluoroquinolone agents. Also discussed are the assessment procedures of regulatory agencies in Europe and the United States that are in place to evaluate antimicrobial safety more accurately. Offsetting potential risks and benefits associated with currently available antimicrobials in a climate in which new agents are desperately needed to combat continually evolving multiresistant pathogens remains an interesting dilemma in antimicrobial therapy.

Antibiotics for community-acquired pneumonia in children

BACKGROUND

Pneumonia caused by bacterial pathogens is the leading cause of mortality in children in low-income countries. Early administration of antibiotics improves outcomes.

OBJECTIVES

To identify effective antibiotics for community acquired pneumonia (CAP) in children by comparing various antibiotics.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, issue 2) which contains the Cochrane Acute Respiratory Infections Group's Specialised Register; MEDLINE (1966 to September 2009); and EMBASE (1990 to September 2009).

SELECTION CRITERIA

Randomised controlled trials (RCTs) in children of either sex, comparing at least two antibiotics for CAP within hospital or ambulatory (outpatient) settings.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data from full articles of selected studies.

MAIN RESULTS

There were 27 studies, which enroled 11,928 children, comparing multiple antibiotics. None compared antibiotic with placebo.For ambulatory treatment of non-severe CAP, amoxycillin compared with co-trimoxazole had similar failure rates (OR 0.92; 95% CI 0.58 to 1.47) and cure rates (OR 1.12; 95% CI 0.61 to 2.03). (Three studies involved 3952 children).In children hospitalised with severe CAP, oral amoxycillin compared with injectable penicillin or ampicillin had similar failure rates (OR 0.95; 95% CI 0.78 to 1.15). (Three studies involved 3942 children). Relapse rates were similar in the two groups (OR 1.28; 95% CI 0.34 to 4.82).In very severe CAP, death rates were higher in children receiving chloramphenicol compared to those receiving penicillin/ampicillin plus gentamycin (OR 1.25; 95% CI 0.76 to 2.07). (One study involved 1116 children).

AUTHORS' CONCLUSIONS

There were many studies with different methodologies investigating multiple antibiotics. For treatment of ambulatory patients with CAP, amoxycillin is an alternative to co-trimoxazole. With limited data on other antibiotics, co-amoxyclavulanic acid and cefpodoxime may be alternative second-line drugs. For severe pneumonia without hypoxia, oral amoxycillin may be an alternative to injectable penicillin in hospitalised children; however, for ambulatory treatment of such patients with oral antibiotics, more studies in community settings are required. For children hospitalised with severe and very severe CAP, penicillin/ampicillin plus gentamycin is superior to chloramphenicol. The other alternative drugs for such patients are ceftrioxone, levofloxacin, co-amoxyclavulanic acid and cefuroxime. Until more studies are available, these can be used as a second-line therapy.There is a need for more studies with larger patient populations and similar methodologies to compare newer antibiotics.

Antibiotics for community acquired pneumonia in adult outpatients

BACKGROUND

Community-acquired pneumonia (CAP), the sixth most common cause of death worldwide, is a common condition representing a significant disease burden for the community, particularly in the elderly. Antibiotics are helpful in treating CAP and are the standard treatment. CAP contributes significantly to antibiotic use, which is associated with the development of bacterial resistance and side-effects. Several studies have been published concerning treatment for CAP. Available data arises mainly hospitalized patients studies. This is an update of our 2004 Cochrane Review.

OBJECTIVES

To summarize current evidence from randomized controlled trials (RCTs) concerning the efficacy of different antibiotic treatments for CAP in participants older than 12.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2009, issue 1) which contains the Cochrane Acute Respiratory Infections Group's Specialized Register; MEDLINE (January 1966 to February week 2, 2009), and EMBASE (January 1974 to February 2009).

SELECTION CRITERIA

RCTs in which one or more antibiotics were tested for the treatment of CAP in ambulatory adolescents or adults. Studies testing one or more antibiotics and reporting the diagnostic criteria as well as the clinical outcomes achieved, were considered for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors (LMB, TJMV) independently assessed study reports in the first publication. In this update, LMB performed study selection, which was checked by TJMV and MMK. Study authors were contacted to resolve any ambiguities in the study reports. Data were compiled and analyzed. Differences between review authors were resolved by discussion and consensus.

MAIN RESULTS

Six RCTs assessing five antibiotic pairs (1857 participants aged 12 years and older diagnosed with CAP) were included. The study quality was generally good, with some differences in the extent of the reporting. A variety of clinical, radiological and bacteriological diagnostic criteria and outcomes were reported. Overall, there was no significant difference in the efficacy of the various antibiotics.

AUTHORS' CONCLUSIONS

Currently available evidence from RCTs is insufficient to make evidence-based recommendations for the choice of antibiotic to be used for the treatment of CAP in ambulatory patients. 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. Multi-drug comparisons using similar administration schedules are needed to provide the evidence necessary for practice recommendations.

Pneumonies aiguës communautaires : analyse critique des essais cliniques

Optimal antibiotic treatment of community-acquired pneumonia (CAP) remains controversial. The clinical impact of S. pneumoniae resistance to macrolides is well documented. By contrast high dosage amoxicillin (1 g tid) remains active against such strains and no failure has been reported. The aim of this paper was to review clinical trials in community-acquired pneumonia, published from January 1, 1999, to December 31, 2005. One hundred seventy-three articles were collected, using Medline, 35 of which were analyzed, and 16 finally used. Telithromycin and pristinamycin may be used in mild to moderate CAP. Anti-pneumococcal fluoroquinolones such as levofloxacin and moxifloxacin may be used in at risk patients, but levofloxacin has only been investigated in patients with severe CAP and patients with Legionnaire's disease. Amoxicillin 1 g tid remains the drug of choice for pneumococcal CAP.

Antibiotics for community acquired pneumonia in children

BACKGROUND

Pneumonia is the leading cause of mortality in children. In developing countries, pneumonia is usually caused by bacterial pathogens. The early administration of empirical antibiotics improves the patients' clinical outcomes. There are currently no systematic reviews of clinical trials on this subject.

OBJECTIVES

To identify effective antibiotic drug therapy for community acquired pneumonia (CAP) in children by comparing various antibiotics.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 4, 2005), MEDLINE (OVID) (1966 to January 2006) and EMBASE (WebSPIRS) (1990 to September 2005). There were no language restrictions.

SELECTION CRITERIA

Randomized controlled trials (RCTs) in children of either sex, which compared at least two antibiotics for CAP in hospital or ambulatory settings.

DATA COLLECTION AND ANALYSIS

Data from full articles of selected studies were independently extracted by two authors.

MAIN RESULTS

The review of these studies suggests that for treatment of pneumonia, co-trimoxazole is inferior in efficacy to both amoxycillin (failure rates odds ratio (OR) 1.33; 95% CI 1.05 to 1.67) and procaine penicillin (cure rates OR 2.64; 95% CI 1.57 to 4.45). Penicillin in conjunction with gentamycin was better than chloramphenicol alone (re-hospitalization rates OR 1.61; 95% CI 1.02 to 2.55). Co-amoxyclavulanic acid was better than amoxycillin alone (cure rates OR 10.44; 95% CI 2.85 to 38.21). There was no differences between injectable penicillin and oral amoxycillin (failure rates OR 1.03; 95% CI 0.81 to 1.31); azithromycin and erythromycin (cure rates OR 1.17; 95% CI 0.70 to 1.95); cefpodoxime and amoxycillin (cure rates OR 0.69; 95% CI 0.18 to 2.60); or azithromycin and co-amoxyclavulanic acid (cure rates OR 1.02; 95% CI 0.54 to 1.95, failure rates OR 1.42; 95% CI 0.43 to 4.66).

AUTHORS' CONCLUSIONS

There were many studies each investigating multiple antibiotics with different methodologies. For treatment of ambulatory patients with CAP, amoxycillin was better than co-trimoxazole; there was no difference between azithromycin and erythromycin, or between cefpodoxime and co-amoxyclavulanic acid. For hospitalized patients, procaine penicillin was better than co-trimoxazole; and the combination of penicillin and gentamycin was better than chloramphenicol alone. Injectable penicillin and oral amoxycillin had similar failure rates. For the rest of the antibiotics there were only single studies available. There is a need for more studies with large patient populations and similar methodologies in order to compare newer antibiotics.

Meta-analysis of bacterial resistance to macrolides

OBJECTIVES

Understanding changing resistance patterns is important in determining appropriate antibiotic treatments. This meta-analysis systematically evaluated resistance of Streptococcus pneumoniae and Streptococcus pyogenes to macrolide antibiotics among patients with community-acquired respiratory tract infections.

METHODS

MEDLINE and EMBASE databases were searched and experts were consulted to identify published and unpublished literature reporting macrolide resistance rates. Identified studies were evaluated by two independent reviewers; those meeting a priori specified criteria (resistance by patient condition and strain, resistance thresholds, 1997-2003 isolates) were included. Data from included studies were abstracted by two independent reviewers using a standard review form. Discrepancies in abstracted data were resolved by the study investigator.

RESULTS

Random-effects meta-analysis was performed for outcomes present in at least four studies overall and for specified subgroups. We identified 3849 studies and performed detailed review on 407; of these 29, published between 1998-2003, met the inclusion criteria. Mean resistance of S. pneumoniae isolates to azithromycin was 27.2% [95% confidence interval (CI) 24.6-29.7]; mean resistance to erythromycin was statistically equivalent (30.4%; 95% CI 28.1-32.7). Resistance of S. pyogenes to erythromycin (30.0%; CI 18.6-41.5) was similar to that of S. pneumoniae. Too few studies of clarithromycin were included to allow evaluation of resistance. In subgroup analyses, substantial variation in resistance to erythromycin was seen by geographic area.

CONCLUSIONS

Reported macrolide resistance of S. pneumoniae varies substantially and may be a significant issue in certain regions. Use of meta-analysis to aggregate individual studies enabled determination of robust values for macrolide resistance. This information is useful for clinical and policy decision makers in developing appropriate antibiotic strategies.

Clarithromycin in 2003: sustained efficacy and safety in an era of rising antibiotic resistance

Data from surveillance studies show increasing prevalence of respiratory pathogens resistant to commonly used antibiotics. Thus, a Medline search was conducted to identify studies of clarithromycin, especially those addressing macrolide resistance. Changing trends of in vitro susceptibility have not affected clinical efficacy with clarithromycin. Over the last 12 years, clarithromycin study results have shown consistent rates of clinical cure and bacteriological eradication, which are similar to those observed with comparator agents. The incidence of clarithromycin treatment failure in patients infected with Streptococcus pneumoniae is substantially less than that predicted by macrolide resistance rates from surveillance programmes. In summary, despite widespread use since its introduction, clarithromycin remains active both in vitro and in vivo against clinically relevant respiratory tract pathogens.