Monotherapy versus combination antimicrobial therapy for pneumococcal pneumonia.

PURPOSE OF REVIEW: 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.

RECENT FINDINGS: 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.

SUMMARY: 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.