Respiratory fluoroquinolones for the treatment of community-acquired pneumonia: a meta-analysis of randomized controlled trials

Abstract

Background: We investigated whether the use of respiratory fluoroquinolones was associated with better clinical outcomes compared with the use of macrolides and beta- lactams among adults with pneumonia.

Methods: We searched PubMed, Current Contents, Scopus, EMBASE, ClinicalTrials.gov and Cochrane with no language restrictions. Two reviewers independently extracted data from published trials that compared fluoroquinolones (levofloxacin, moxifloxacin, gemifloxacin) with macrolides or beta-lactams or both. A meta-analysis was performed with the clinical outcomes of mortality, treatment success and adverse outcomes.

Results: We included 23 trials in our meta-analysis. There was no difference in mortality among patients who received fluoroquinolones or the comparator antibiotics (OR 0.85, 95% CI 0.65-1.12). Pneumonia resolved in more patients who received fluoroquinolones compared with the comparator antibiotics for the included outcomes in the intention-to-treat population (OR 1.17, 95% CI 1.00-1.36), clinically evaluable population (OR 1.26, 95% CI 1.06-1.50) and the microbiologically assessed population (OR 1.67, 95% CI 1.28-2.20). Fluoroquinolones were more effective than a combination of beta-lactam and macrolide (OR 1.39, 95% CI 1.02-1.90). They were also more effective for patients with severe pneumonia (OR 1.84, 95% CI 1.02-3.29), those who required admission to hospital (OR = 1.30, 95% CI 1.04-1.61) and those who required intravenous therapy (OR = 1.44, 15% CI 1.13-1.85). Fluoroquinolones were more effective than beta-lactam and macrolide in open-label trials (OR = 1.35, 95% CI 1.08-1.69) but not in blinded randomized controlled trials (OR = 1.13, 95% CI 0.85-1.50).

Interpretation: Fluoroquinolones were associated with higher success of treatment for severe forms of pneumonia; however, a benefit in mortality was not evident. A randomized controlled trial that includes patients with severe pneumonia with or without bacteremia is needed.

Figure 1: Retrieval and selection of randomized controlled trials for inclusion in the meta-analysis of the effectiveness of fluoroquinolones for the treatment of pneumonia.

Figure 2: Effect of fluoroquinolones on mortality among patients with pneumonia in the intention-to-treat population. Test for heterogeneity: χ² = 14.25, p = 0.65, I² = 0%. Test for overall effect: z = 1.12, p = 0.26. Note: CI = confidence interval.

Figure 3: Odds ratios for treatment success with fluoroquinolone therapy among patients with pneumonia for the intention-to-treat and clinically evaluable populations. Test for heterogeneity: χ² = 6.49, p = 0.95, I² = 0%. Test for overall effect: z = 1.96, p = 0.05. Note: CI = confidence interval.

Figure 4: Odds ratios for adverse outcomes after fluoroquinolone therapy among patients with pneumonia in the intention-to-treat population. Test for heterogeneity: χ² = 22.81, p = 0.30, I² = 12.3%. Test for overall effect: z = 2.72, p = 0.007. Note: CI = confidence interval.