Clin Microbiol Infect. 2022 Jan 14:S1198-743X(21)00729-1. doi: 10.1016/j.cmi.2021.12.021. Online ahead of print.
BACKGROUND: Bactericidal antibiotics are generally assumed to be superior to bacteriostatic antibiotics as first-line treatment for pneumonia.
OBJECTIVES: We performed a systematic review, meta-analysis, and trial sequential analysis (TSA) of randomized controlled trials (RCTs) of bactericidal versus bacteriostatic antibiotics to ascertain clinical superiority. Clinical cure rate was the primary outcome. Secondary outcomes included all-cause mortality, microbiological eradication, treatment failure, and relapse rates.
DATA SOURCES: PubMed, Cochrane Library, Embase, and MedRxiv STUDY ELIGIBILITY CRITERIA: Randomized control trials.
PARTICIAPANTS: Adult patients with bacterial pneumonia treated with antibiotics in the community or in-hospital.
INTERVENTIONS: Bacteriostatic versus bactericidal antibiotics.
ASSESSMENT OF RISK OF BIAS: The Cochrane Collaboration assessing risk of bias 2 tool.
METHODS OF DATA SYNTHESIS: Data on dichotomous outcomes are presented as risk ratio (RR). A random-effects model with the generic Mantel-Haenszel method was used for integrating RRs for generalizability of findings. The I2 method was used to assess the magnitude of variation secondary to heterogeneity.
RESULTS: Forty-three RCTs involving 10 752 patients met the eligibility criteria. The clinical cure rate (42 studies, 10 312 patients; RR: 1.02; 95% CI, 0.99-1.05; I2: 37%; TSA-adjusted CI, 0.99-1.05), all-cause mortality (25 studies, 8302 patients; RR: 1.07; 95% CI, 0.81-1.42; I2: 57%), microbiological eradication (24 studies, 2776 patients; RR: 1.00; 95% CI, 0.97-1.03; I2: 0%), treatment failure (31 studies, 7296 patients; RR: 0.96; 95% CI, 0.83-1.11; I2: 42%), and relapse rate (5 studies, 1111 patients; RR: 1.15; 95% CI, 0.50-2.63; I2: 0%) were similar between bactericidal and bacteriostatic antibiotic treatments.
CONCLUSIONS: Bactericidal agents are not associated with any statistical difference in clinical cure rates, mortality, microbiological eradication, treatment failure, or relapse rates compared with bacteriostatic antibiotics in the treatment of pneumonia.