The dilemma of monotherapy or combination therapy in community-acquired pneumonia.
SCOPE
To study the factors associated with mortality in hospitalized patients with community-acquired pneumonia treated with monotherapy or combination therapy.


METHODS
PubMed and Scopus were searched. Patients receiving macrolides, β-lactams and fluoroquinolones, as monotherapy or in combination, were included. Meta-analyses and meta-regressions were performed.


RESULTS
Fifty studies were included. Overall, monotherapy was not associated with higher mortality than combination (RR 1.14, 95% CI 0.99-1.32, I2 84%). Monotherapy was associated with higher mortality than combination in North American and retrospective studies. β-lactam monotherapy was associated with higher mortality than β-lactam/macrolide combination in the primary (1.32, 1.12-1.56, I2 85%) and most sensitivity analyses. There was no difference in mortality between fluoroquinolone monotherapy and β-lactam/macrolide combination (0.98, 0.78-1.23, I2 73%). In meta-regressions, the moderators that could partially explain the observed statistical heterogeneity were the frequency of cancer patients (P = .03) and Pneumonia Severity Index score IV (P = .008).


CONCLUSION
Due to the considerable heterogeneity and inclusion of unadjusted data, it is difficult to recommend a specific antibiotic regimen over another. Specific antibiotic regimens, study design and the characteristics of the population under study seem to influence the reported outcomes.
['Vardakas|Konstantinos Z|KZ|http://orcid.org/0000-0001-9959-2242', 'Trigkidis|Kyriakos K|KK|', 'Apiranthiti|Katerina N|KN|', 'Falagas|Matthew E|ME|http://orcid.org/0000-0002-5905-2695']
D000900:Anti-Bacterial Agents D002511:Cephalosporins D017714:Community-Acquired Infections D004359:Drug Therapy, Combination D024841:Fluoroquinolones D017052:Hospital Mortality D006760:Hospitalization D006801:Humans D018942:Macrolides D011014:Pneumonia D047090:beta-Lactams
azithromycin cephalosporin ciprofloxacin clarithromycin levofloxacin moxifloxacin