Guideline for Antibiotic Use in Adults with Community-acquired Pneumonia

Lee, Mi Suk; Oh, Jee Youn; Kang, Cheol-In; Kim, Eu Suk; Park, Sunghoon; Rhee, Chin Kook; Jung, Ji Ye; Jo, Kyung-Wook; Heo, Eun Young; Park, Dong-Ah; Suh, Gee Young; Kiem, Sungmin

Use of β-lactams or respiratory fluoroquinolone alone is recommended for the empirical treatment of mild or moderate pneumonia. The 2007 IDSA/ATS guideline and the 2009 Korean guideline on community-acquired pneumonia recommend the administration of β-lactams alone or in conjunction with macrolide, or the administration of respiratory fluoroquinolones alone [15, 104] . Most of the studies on combined antibiotic administration included in these guidelines were either retrospective or observational studies [138] [139] [140] [141] . In prospective comparative studies conducted after these studies, the β-lactam and macrolide combination therapy for mild-moderate pneumonia showed no difference from the β-lactam monotherapy in terms of treatment outcomes (cure rate, incidence of side effects, mortality rates, etc.) [130-132, 142, 143] . In a meta-analysis on 18 studies that compare the therapeutic effects of β-lactams, and those of macrolide or fluoroquinolone which have the effect to atypical pathogens, in the treatment of mild-moderate pneumonia, there were no significant differences in the clinical progress between the two antibiotic groups (relative risk, 0.97; 95% confidence interval 0.87-1.07) [130] . In a prospective CAP-START study conducted by Postma et al., patients hospitalized in general wards were subjected to β-lactam administration (656 patients), β-lactam + macrolide administration (739 patients), and fluoroquinolone administration (888 patients), and therapeutic effects were compared among the groups. The 90-day mortality rate was 9.0% in the β-lactam group, 11.1% in the β-lactam + macrolide group, and 8.8% in the fluoroquinolone group. Therefore, the treatment outcomes observed in the β-lactam group were on a par with those observed in the other groups [144] . In a study by Grain et al. that prospectively compares β-lactam administration, and β-lactam + macrolide administration in the treatment of patients with severe pneumonia, 41.2% and 33.6% of the patients in the β-lactam group, and the β-lactam + macrolide group did not reach a clinically stable state after seven days, respectively (P = 0.07). Although there was no difference in the rate of reaching clinical stability between the patients without atypical bacterial infection (relative risk, 0.99; 95% CI, 0.80-1.22) and with pneumonia corresponding to PSI 1-3 points in the β-lactam, and β-lactam + macrolide groups, when patients with atypical pneumonia (relative risk, 0.33; 95% confidence interval, 0.13-0.85) or severe pneumonia corresponding to PSI 5 points (relative risk, 0.81; 95% confidence interval, 0.59-1.10) were considered, the rate of reaching clinical stability was lower in the β-lactam group. The rate of readmission within 30 days was higher in the β-lactam group (7.9%, 3.1%, P = 0.01), and there were no significant differences in other clinical markers including the 90-day mortality rate, rate of ICU admission, incidence of complications, duration of hospital stay, and rate of pneumonia recurrence between the two administration groups [142] .