CLINICAL QUESTION

What is the best oral treatment for mild to moderate community-acquired pneumonia?

BOTTOM LINE

Using clarithromycin as the standard, telithromycin, azithromycin, amoxicillin/clavulanate, and the quinolones levofloxacin and nemonoxacin (not available in the United States) produce similar benefits regarding clinical response and mortality. Amoxicillin and penicillin may not work as well. Doxycycline is recommended in some guidelines, but it was not included in this analysis. (Level of Evidence = 1a)

SYNOPSIS

The researchers identified 24 randomized controlled trials of oral treatment for mild to moderate community-acquired pneumonia in adults confirmed with imaging by searching two databases, including Cochrane CENTRAL, and the reference lists of practice guidelines and review articles. They included all the research written in one of four languages. Pairs of investigators selected articles for inclusion, abstracted the data, and evaluated the research for risk of bias. Because few studies compared antibiotics directly, the authors used a network meta-analysis to estimate differences in response. No antibiotic produced statistically superior results to clarithromycin. Compared with clarithromycin, clinical response was best (but still similar to clarithromycin) with nemonoxacin, levofloxacin, and telithromycin. Nemonoxacin, levofloxacin, azithromycin, and amoxicillin/clavulanate had lower mortality. Penicillin and amoxicillin produced lower clinical response. One-half of the studies were deemed to be at high risk of bias due to breaches in modern conduct of clinical trials (e.g., not masking the participants and evaluators, selected reporting of outcomes). There was no evidence of publication bias, but studies of doxycycline were excluded because they were published too long ago.

Study design: Meta-analysis (randomized controlled trials)

Funding source: Self-funded or unfunded

Setting: Various (meta-analysis)

Reference: Kurotschka PK, Bentivegna M, Hulme C, et al. Identifying the best initial oral antibiotics for adults with community-acquired pneumonia: a network meta-analysis. J Gen Intern Med. 2024;39(7):1214-1226.

Editor's Note: Dr. Shaughnessy is an assistant medical editor for AFP.