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Original Investigation
December 2014

β-Lactam Monotherapy vs β-Lactam–Macrolide Combination Treatment in Moderately Severe Community-Acquired Pneumonia: A Randomized Noninferiority Trial

Author Affiliations
  • 1Division of General Internal Medicine, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
  • 2Division of Internal Medicine, Hôpital Riviera-Chablais, Monthey, Switzerland
  • 3Division of Internal Medicine, Hôpital Neuchâtelois–La Chaux-de-Fonds, La Chaux-de-Fonds, Switzerland
  • 4Division of Internal Medicine, Hôpital Cantonal, Fribourg, Switzerland
  • 5Division of Internal Medicine, Triemlispital, Zurich, Switzerland
  • 6Emergency Department, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
  • 7Division of Internal Medicine, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
  • 8Division of Internal Medicine, Hôpital du Valais, Sion, Switzerland
  • 9Division of Clinical Epidemiology, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
  • 10Emergency Department, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
  • 11Division of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
JAMA Intern Med. 2014;174(12):1894-1901. doi:10.1001/jamainternmed.2014.4887
Abstract

Importance  The clinical benefit of adding a macrolide to a β-lactam for empirical treatment of moderately severe community-acquired pneumonia remains controversial.

Objective  To test noninferiority of a β-lactam alone compared with a β-lactam and macrolide combination in moderately severe community-acquired pneumonia.

Design, Setting, and Participants  Open-label, multicenter, noninferiority, randomized trial conducted from January 13, 2009, through January 31, 2013, in 580 immunocompetent adult patients hospitalized in 6 acute care hospitals in Switzerland for moderately severe community-acquired pneumonia. Follow-up extended to 90 days. Outcome assessors were masked to treatment allocation.

Interventions  Patients were treated with a β-lactam and a macrolide (combination arm) or with a β-lactam alone (monotherapy arm). Legionella pneumophila infection was systematically searched and treated by addition of a macrolide to the monotherapy arm.

Main Outcomes and Measures  Proportion of patients not reaching clinical stability (heart rate <100/min, systolic blood pressure >90 mm Hg, temperature <38.0°C, respiratory rate <24/min, and oxygen saturation >90% on room air) at day 7.

Results  After 7 days of treatment, 120 of 291 patients (41.2%) in the monotherapy arm vs 97 of 289 (33.6%) in the combination arm had not reached clinical stability (7.6% difference, P = .07). The upper limit of the 1-sided 90% CI was 13.0%, exceeding the predefined noninferiority boundary of 8%. Patients infected with atypical pathogens (hazard ratio [HR], 0.33; 95% CI, 0.13-0.85) or with Pneumonia Severity Index (PSI) category IV pneumonia (HR, 0.81; 95% CI, 0.59-1.10) were less likely to reach clinical stability with monotherapy, whereas patients not infected with atypical pathogens (HR, 0.99; 95% CI, 0.80-1.22) or with PSI category I to III pneumonia (HR, 1.06; 95% CI, 0.82-1.36) had equivalent outcomes in the 2 arms. There were more 30-day readmissions in the monotherapy arm (7.9% vs 3.1%, P = .01). Mortality, intensive care unit admission, complications, length of stay, and recurrence of pneumonia within 90 days did not differ between the 2 arms.

Conclusions and Relevance  We did not find noninferiority of β-lactam monotherapy in patients hospitalized for moderately severe community-acquired pneumonia. Patients infected with atypical pathogens or with PSI category IV pneumonia had delayed clinical stability with monotherapy.

Trial Registration  clinicaltrials.gov Identifier: NCT00818610

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