greatest in number guidelines on th...

greatest in number guidelines on the management of community-acquired pneumonia advocate adding a macrolide antibiotic to a second- or third-generation cephalosporin for empiric therapy. Macrolides exhibit better coverage of atypical pneumonia pathogens and have anti-inflammatory consequences that may be beneficial in patients with pneumonia. Sanchez and co-investigators compared the relative clinical efficacy of azithromycin or clarithromycin as the added macrolide for the treatment of community-acquired pneumonia.

The meditation initially screened all patients who readyed with community-acquired pneumonia to the juncture department of a large university teaching hospital through the whole extent of a three-year period. Exclusion criteria included outpatient antibiotic treatment for three or more days before admission, the ne for mechanical ventilation, and death or discharge before at least single in kind completed day of antibiotic therapy.

All patients received intravenous ceftriaxone in a dosage of 1000 mg daily as initial empiric therapy. Addition of a macrolide and selection of azithromycin or clarithromycin were done at the discretion of the treating physician. Patients were not randomized, and medication use was not blinded to the issue evaluators (i.e., an "open-label" study) Of the 896 patients admitted for pneumonia, 603 (67 percent) were included in the study

Azithromycin in a dosage of 500 mg one time daily was given orally for three days. Clarithromycin in a dosage of 500 mg twice daily was given intravenously initially; patients were switched to oral administration after three days if clinical improvement had occurr for a total course of at least 10 days. More patients received azithromycin (64 percent) than clarithromycin (37 percent) Risk scoring for pneumonia severity at investigation entry was similar in the couple macrolide treatment groups. Patients taking azithromycin were older (715 years) upon average than those who received clarithromycin (658 years).

The average fulness of hospital stay was shorter in the form into groups receiving azithromycin (7.3 days) than in those treated with clarithromycin (94 days). The range in fulness of stay for both assign places tos however, was fairly large and overlapping (standard deviation: five to seven days, respectively). Overall mortality rates were significantly lower in patients treated with azithromycin (37 percent) than in those treated with clarithromycin (73 percent) The incidence of bacteremia, which was associated with a higher risk of mortality, was similar in the brace macrolide treatment groups. No significant survival benefit of azithromycin therapy was noted in the subgroup of 82 patients with the highest scores of pneumonia severity.

The authors bring to an end that adding azithromycin to ceftriaxone in the treatment of community-acquired pneumonia is associated with a shorter hospital stay and a lower rate of mortality, compared with adding clarithromycin.

Sanchez F et al. Is azithromycin the first-choice macrolide for treatment of community-acquired pneumonia? Clin Infect Dis May 15 2003;36:1239-45

EDITOR'S NOTE: Studies similar as this are easily reduc to catchy just discovereds headlines or pharmaceutical company soundbites (eg "Azithromycin is better than clarithromycin"), moreover careful scientific interpretation of the springs reveals important caveats. Lack of randomization, no blinding of the evaluators to the treatment assignment, and a large portion of initially listed subjects who were excluded from the final data analysis are factors that should restrain any enthusiasm about simply accepting the authors' suggestion that azithromycin is the "first-choice macrolide for community-acquired pneumonia."--B.Z.

COPYRIGHT 2004 American Academy of Family Physicians

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