There are several antibiotic regimens to treat community-acquired pneumonia (CAP).
In patients hospitalized to a non-ICU ward setting with CAP, is there a difference between first-line and alternative antibiotic regimens (β-lactam plus macrolide (BL+M), β-lactam alone (BL), respiratory fluoroquinolone (FQ) or β-lactam plus doxycycline (BL+D)) in terms of in-hospital mortality?
This retrospective cohort study included consecutive patients admitted with CAP at 19 Canadian hospitals from 2015 to 2021. Taking a target-trial approach, patients were categorized into the 4 antibiotic groups based on the initial antibiotic treatment within 48 hours of admission. Patients with severe CAP requiring intensive care unit admission in the first 48 hours were excluded. The primary outcome was all-cause in-hospital mortality. Secondary outcomes included time to being discharged alive. Propensity score and overlap weighting were used to balance covariates.
Of 23,512 patients, 9,340 (39.7%) patients received BL+M, 9,146 (38.9%) received BL, 4,510 (19.2%) received FQ, and 516 (2.2%) received BL+D. The number of in-hospital deaths was 703 (7.5%) for BL+M group, 888 (9.7%) for BL group, 302 (6.7%) for FQ group and 31 (6.0%) for BL+D group. The adjusted risk difference for in-hospital mortality when compared to BL+M was 1.5% (95%CI -0.3% to 3.3%) for BL, -0.9% (95%CI -2.9% to 1.1%) for FQ, and -1.9% (95%CI -4.8% to 0.9%) for BL+D. Compared to BL+M, the sub-distribution hazard ratio for being discharged alive was 0.90 (95%CI 0.84 to 0.96) for BL, 1.07 (95%CI 0.99 to 1.16) for FQ, and 1.04 (95%CI 0.93 to 1.17) for BL+D.
BL+M, FQ and BL+D had similar outcomes and can be considered effective regimens for non-severe CAP. Compared to BL+M, BL was associated with longer time to discharge and the confidence interval for mortality cannot exclude a small but clinically important increase in risk.

Copyright © 2023. Published by Elsevier Inc.