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

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Abstract

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.

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Data Availability

The data used to perform the network meta-analysis are available upon reasonable request from the authors, with an expectation of collaboration in any additional analyses.

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Funding

No project-specific funding. PK is supported by funds of the Bavarian State Ministry of Science and Arts and the University of Würzburg to the Graduate School of Life Sciences (GSLS), University of Würzburg, Germany.

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Authors and Affiliations

  1. Department of General Practice, University Hospital Würzburg, Würzburg, Germany

    Peter K. Kurotschka MD

  2. Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, USA

    Michelle Bentivegna MPH, PhD, Cassie Hulme MPH, PhD & Mark H. Ebell MD, MS

Authors
  1. Peter K. Kurotschka MD
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  2. Michelle Bentivegna MPH, PhD
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  3. Cassie Hulme MPH, PhD
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  4. Mark H. Ebell MD, MS
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Contributions

MHE conceived the study and is primarily accountable for the study design. MB and CH performed the initial literature searches, retrieved eligible studies, abstracted data, and maintained the databases. MHE and PK performed the additional searches, selected eligible studies, and abstracted data. MHE and PK assessed study quality. MHE (with contributions of PK) performed data analysis. MHE and PK interpreted the results and drafted the manuscript. All authors made relevant amendments to the manuscript and approved its final version.

Corresponding author

Correspondence to Mark H. Ebell MD, MS.

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Kurotschka, P.K., Bentivegna, M., Hulme, C. et al. Identifying the Best Initial Oral Antibiotics for Adults with Community-Acquired Pneumonia: A Network Meta-Analysis. J GEN INTERN MED (2024). https://doi.org/10.1007/s11606-024-08674-1

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