Narrow-Spectrum Antibiotics Appear Effective and Safe for Community Acquired Pneumonia

By Lorraine L. Janeczko

October 28, 2021

NEW YORK (Reuters Health) - Using narrow-spectrum antibiotics to treat community-acquired pneumonia appears to be safe and effective, a study of patients in the Netherlands suggests.

"Antimicrobial resistance is increasing," Dr. Valentijn A. Schweitzer of the University Medical Center Utrecht told Reuters Health by email. "Our study shows that antimicrobial stewardship programs are effective and safe in decreasing broad-spectrum antibiotic use in patients with moderately severe community-acquired pneumonia."

"Implementing effective antimicrobial stewardship programs will be an important contribution in the battle against antimicrobial resistance," he said.

As reported in The Lancet Infectious Diseases, Dr. Schweitzer and his colleagues conducted the stepped-wedge, cluster-randomized, non-inferiority CAP-PACT trial over two years in 12 hospitals in the Netherlands. They enrolled immunocompetent adults admitted to non-ICU wards with moderately severe community-acquired pneumonia.

After an initial control period, two randomly chosen hospitals transitioned to the intervention period every three months until all hospitals adopted the intervention to decrease broad-spectrum antibiotics. Generally, amoxicillin was administered either intravenously at 1,000 mg every six hours or orally at 500 mg or 750 mg every eight hours; while benzylpenicillin was given intravenously at 1 million units every four or six hours. The intervention included education, engagement with opinion leaders, and audit of and feedback about the antibiotics used.

Of the more than 4,000s patients included in the analysis, 2,235 were admitted during the control period and 1,849 were admitted during the intervention. During the intervention, the adjusted mean broad-spectrum days of therapy per patient dropped by a significant 26.6%, from 6.5 days in the control period to 4.8 days during the intervention.

The increased use of narrow-spectrum beta-lactam monotherapy with benzylpenicillin or amoxicillin did not affect the 90-day all-cause mortality, which was 10.9% in the control period vs. 10.8% during the intervention.

"Finding opportunities to safely use narrow antibiotics instead of broad-spectrum antibiotics is a key strategy to fighting the spread of antibiotic resistance," said Dr. Daniel J. Livorsi, an assistant professor of internal medicine-infectious diseases at University of Iowa Health Care in Iowa City, who was not involved in the study.

"Dutch guidelines for treating community-acquired pneumonia are very different from U.S. guidelines," he told Reuters Health by email. "Because of these differences, I doubt doctors in the U.S. would be willing to use penicillin or amoxicillin as empiric, or initial, therapy in hospitalized, non-ICU patients with community-acquired pneumonia. Doctors would be more willing to use these more narrow antibiotics when the cause of pneumonia has been identified to be bacteria susceptible to these drugs."

"The types of bacteria that cause pneumonia, and the patterns of antibiotic resistance, may vary across different countries," added Dr. Livorsi. "The variation may make it difficult to apply this study from the Netherlands to other settings."

Dr. Jared J. Eddy, the director of infection control and prevention and of antimicrobial stewardship at National Jewish Health in Denver, Colorado, who also was not involved in the research, told Reuters Health by email, "To make real gains in this area, we need better diagnostics to quickly detect the pathogens causing pneumonia and antibiotic resistance patterns. Until that is achieved, sicker patients will continue to receive broad-spectrum antibiotics that may even be less effective than narrower 'tailored' therapy."

In an accompanying editorial, Drs. Maddalena Peghin of the Universita degli Studi di Udine, in Italy, and Emilio Bouza of the Universidad Complutense de Madrid, in Spain, write, "Community-acquired pneumonia is a topic of maximum interest because it remains a leading cause of morbidity and mortality due to an infection."

Studies like this "indicate that antimicrobial stewardship programmes can promote appropriate antimicrobial use without deleterious effects on clinical outcomes in patients with community-acquired pneumonia," they add," but more prospective and randomised studies are needed in this field."

The study was not funded.

SOURCES: and The Lancet Infectious Diseases, online October 7, 2021.