Single vs Multiple Antibiotics in Community-Acquired Pneumonia

By Richard G. Wunderink, MD, FCCP; and Grant W. Waterer, MBBS, FCCP

Single vs Multiple Antibiotics for Pneumococcal CAP

Until recently, the debate regarding monotherapy and combination therapy was mainly a response to the difficulty in making an etiologic diagnosis, with the assumption that the benefit of combination therapy was coverage of a broader range of causative etiologies. However, recent data have suggested an alternative explanation. Waterer et al¹⁹ retrospectively reviewed antibiotic treatment of 225 patients with bacteremic pneumococcal CAP. The mortality rates were compared in patients who received one, two, or more than two effective antibiotics in the first 24 h. Somewhat surprisingly, patients who received combination therapy with two drugs fared better than the other two groups (Fig 3). Patients who received more than two effective antibiotics were clearly more ill, as measured by both Acute Physiology and Chronic Health Evaluation (APACHE) scores and the Pneumonia Severity Index.⁵ However, the patients who received monotherapy were equivalent to those receiving dual therapy, yet had an 11.3% absolute mortality difference (18.2 vs 6.9%; p = 0.02). All deaths occurred in patients with a Pneumonia Severity Index score of > 90; in this population, the predicted mortality-adjusted odds ratio for death for single-agent treatment was 5.5.

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