CAP Coverage – Beta Lactam Only?

Written by Megan Hilbert

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In patients hospitalized with non-severe community-acquired pneumonia (CAP), beta-lactam (BL) only antibiotic regimens have been shown to have increased mortality as compared to other first-line regimens.

We shouldn’t be treating with beta-lactam only. No CAP.
This was a retrospective cohort study of patients admitted for non-severe CAP (as defined by requiring admission to a non-ICU setting). There were 4 antibiotic regimens that were compared, with primary outcome of all-cause in-hospital mortality and secondary outcome of time to discharge alive. The regimens included were beta-lactam + macrolide (BL+M), beta-lactam alone (BL), respiratory fluoroquinolone (FQ), and beta-lactam + doxycycline (BL+D). BL only had higher in-hospital mortality with 1.5% adjusted risk difference as well as longer time to clinical stability (defined as discharge alive). It did not, however, have increased adverse effects (dysrhythmia, transfer to ICU, cardiac arrest)  as compared to the other regimens. In fact the regimens otherwise all had similar adjusted risk for adverse effects, with the BL+D demonstrated a slightly decreased risk of development of C. difficile.

This was a well done retrospective cohort study with a large sample size including 23,512 patients. The primary endpoint of in-hospital mortality has clinical significance and can truly guide patient management.

How will this change my practice?
In the management of my patients hospitalized for CAP I will feel comfortable pursuing differing antibiotic regimens depending upon patient factors knowing that they have similar efficacy. I will not, however, use a beta-lactam only approach.

Source
Comparative Effectiveness of First-Line and Alternative Antibiotic Regimens in Hospitalized Patients With Nonsevere Community-Acquired Pneumonia: A Multicenter Retrospective Cohort Study. Chest. 2024 Jan;165(1):68-78. doi: 10.1016/j.chest.2023.08.008. Epub 2023 Aug 11.