Beta lactam monotherapy versus beta lactam-aminoglycoside combination therapy for fever with neutropenia: systematic review and meta-analysis.
OBJECTIVE
To compare the effectiveness of beta lactam monotherapy versus beta lactam-aminoglycoside combination therapy in the treatment of patients with fever and neutropenia.


METHODS
Medline, Embase, Lilacs, the Cochrane Library, and conference proceedings to 2002. References of included studies and contact with authors. No restrictions on language, year of publication, or publication status.


METHODS
All randomised trials of beta lactam monotherapy compared with beta lactam-minoglycoside combination therapy as empirical treatment for patients with fever and neutropenia.


METHODS
Two reviewers independently applied selection criteria, performed quality assessment, and extracted data. An intention to treat approach was used. Relative risks were pooled with the random effect model.


METHODS
All cause fatality.


RESULTS
Forty seven trials with 7807 patients met inclusion criteria. Nine trials compared the same beta lactam. There was no significant difference in all cause fatality (relative risk 0.85, 95% confidence interval 0.72 to 1.02). For success of treatment there was a significant advantage with monotherapy (0.92, 0.85 to 0.99), though there was considerable heterogeneity among trials. There was no significant difference between monotherapy and combination treatment in trials that compared the same beta lactam, whereas there was major advantage with monotherapy in trials that compared different beta lactams (0.87, 0.80 to 0.93). Rates of superinfection were similar. Adverse events, including those associated with severe morbidity, were significantly more common in the combination treatment group. Detected flaws in methods did not affect results.


CONCLUSIONS
For patients with fever and neutropenia there is no clinical advantage in treatment with beta lactam-aminoglycoside combination therapy. Broad spectrum beta lactams as monotherapy should be regarded as the standard of care for such patients.
Paul
Mical
M
Rabin Medical Centre, Beilinson Campus, Infectious Diseases Unit and Department of Medicine E, Petah-Tiqva 49100, Israel. mica@zahav.net.il
Soares-Weiser
Karla
K
Leibovici
Leonard
L
D000617:Aminoglycosides; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D002423:Cause of Death; D004359:Drug Therapy, Combination / Q000627:therapeutic use*; D005334:Fever / Q000188:drug therapy*; D006801:Humans; D009503:Neutropenia / Q000188:drug therapy*; D016032:Randomized Controlled Trials as Topic; D012680:Sensitivity and Specificity; D015163:Superinfection / Q000188:drug therapy; D017211:Treatment Failure; D047090:beta-Lactams
D000617:Aminoglycosides; D000900:Anti-Bacterial Agents; D047090:beta-Lactams