BMJ  2005;330:456 (26 February), doi:10.1136/bmj.38334.591586.82 (published 31 January 2005)

Primary care

Effectiveness of lactam antibiotics compared with antibiotics active against atypical pathogens in non-severe community acquired pneumonia: meta-analysis

¹ Respiratory and Infectious Diseases Department, Waikato Hospital, Private Bag 3200, Hamilton 2001, New Zealand, ² University of Auckland School of Medicine, New Zealand, ³ Department of General Practice and Primary Health Care, University of Auckland, New Zealand

Objective To systematically compare lactam antibiotics with antibiotics active against atypical pathogens in the management of community acquired pneumonia.

Data sources Medline, Embase, Cochrane register of controlled trials, international conference proceedings, drug registration authorities, and pharmaceutical companies.

Review methods Double blind randomised controlled monotherapy trials comparing lactam antibiotics with antibiotics active against atypical pathogens in adults with community acquired pneumonia. Primary outcome was failure to achieve clinical cure or improvement.

Results 18 trials totalling 6749 participants were identified, with most patients having mild to moderate community acquired pneumonia. The summary relative risk for treatment failure in all cause community acquired pneumonia showed no advantage of antibiotics active against atypical pathogens over lactam antibiotics (0.97, 95% confidence interval 0.87 to 1.07). Subgroup analysis was undertaken in those with a specific diagnosis involving atypical pathogens. We found a significantly lower failure rate in patients with Legionella species who were treated with antibiotics active against atypical pathogens (0.40, 0.19 to 0.85). Equivalence was seen for Mycoplasma pneumoniae (0.60, 0.31 to 1.17) and Chlamydia pneumoniae (2.32, 0.67 to 8.03).

Conclusions Evidence is lacking that clinical outcomes are improved by using antibiotics active against atypical pathogens in all cause non-severe community acquired pneumonia. Although such antibiotics were superior in the management of patients later shown to have legionella related pneumonia, this pathogen was rarely responsible for pneumonia within the included trials. lactam agents should remain the antibiotics of initial choice in adults with non-severe community acquired pneumonia.

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