Written by Aaron Lacy
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Among adults with culture-confirmed bacteremic pneumococcal pneumonia, empiric macrolide therapy was associated with a 45% reduction in the odds for mortality, regardless of macrolide treatment duration, an effect not seen with fluoroquinolones.
Why does this matter?
A common cause of hospitalization and death is community acquired pneumonia. In hospitalized patients, guidelines recommend empiric beta-lactam therapy and an advanced macrolide or monotherapy with respiratory quinolone. If one of these options performed better than the other, it would change practice.
Z-Pak for all?
In this retrospective cohort of 2016 Israeli adult patients hospitalized with confirmed bacteremic pneumococcal pneumonia, 1,159 received empiric atypical bacterial coverage with either a quinolone or a macrolide (64%). 61.8% of patients who survived received empiric atypical coverage compared to only 42.4% of non-survivors. Those who received quinolones for atypical coverage did not have a change in survival versus non-survival (19% vs 21%, respectively, p=0.58). However, macrolide therapy usage was associated with a reduction in mortality, with 40% of survivors receiving macrolide therapy and 22% of non-survivors receiving it (p<0.001). This was evident for both azithromycin and roxithromycin.
Once a typical bacterial pathogen is identified with culture data, atypical coverage is often discontinued. The authors found that the effect remained significant even if macrolide treatment was 2 days or less compared to no therapy (OR 0.482, 95%CI 0.289-0.804).
While retrospective, these data are compelling; patients I am admitting to the hospital for CAP should be treated for atypical pathogens, and a macrolide appears to be the best choice. The authors postulate that because macrolides are thought to have anti-inflammatory effects, which quinolones lack, this could be the difference. Regardless, if there is no strong indication for one or the other (past culture data), azithromycin as part of the antibacterial coverage sounds simple enough to me.
Source
The Effect of Macrolides on Mortality In Bacteremic Pneumococcal Pneumonia: A Retrospective Nationwide Cohort Study, Israel, 2009-2017. Clin Infect Dis. 2022 Apr20;ciac317. Doi: 10.1093/cid/ciac317.
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