Monotherapy versus combination antimicrobial therapy for pneumococcal pneumonia.
OBJECTIVE
In the past 5 years a number of studies have suggested that combination antibiotic therapy may be superior to monotherapy for pneumococcal pneumonia. This review outlines the major findings for and against combination therapy.


RESULTS
The evidence for a benefit of multiple antibiotics is strongest in patients with severe, bacteremic pneumococcal disease. All of these studies have limitations due to their retrospective or uncontrolled design. Unfortunately prospective, randomized, double-blind, controlled studies have not been performed in an appropriately severe disease cohort and are therefore urgently needed. Several viable mechanisms for a benefit of combination therapy have been proposed, especially related to non-antibiotic effects of macrolides. There is also some evidence that third-generation cephalosporins may be superior to penicillins as the non-macrolide component of combination therapy.


CONCLUSIONS
Although based on retrospective and observational data, there is substantial evidence to support combination antibiotic therapy, at least in patients with severe bacteremic pneumococcal pneumonia. What evidence is available supports a cephalosporin/macrolide combination as being associated with the highest survival, but proper prospective studies in patients with severe pneumonia are urgently required to clarify this issue.
Waterer
Grant W
GW
Department of Medicine, University of Western Australia, Perth, Western Australia, Australia. waterer@cyllene.uwa.edu.au
D000900:Anti-Bacterial Agents / Q000008:administration & dosage* / Q000627:therapeutic use; D017714:Community-Acquired Infections / Q000188:drug therapy; D004359:Drug Therapy, Combination; D006801:Humans; D011018:Pneumonia, Pneumococcal / Q000188:drug therapy* / Q000453:epidemiology
D000900:Anti-Bacterial Agents