Little research exists on whether monotherapy (MT) is appropriate for patients with severe community-acquired pneumonia (SCAP). Our goal was to conduct a systematic review to examine whether published research supports the use of combination therapy (CT) versus MT for SCAP.METHODS: We searched the Cochrane Controlled Trials Register, Cochrane Library Database, EMBASE, and MEDLINE for the period of January 1990 to October 2002. We scanned references of all included studies and pertinent reviews. Articles were selected if they were randomized controlled trials (RCT), controlled trials, or cohort studies using MT or any CT. Other inclusion criteria included subjects over 18 years of age, meet formal criteria for SCAP, and had sufficient information to compare the use of MT and CT. Data was extracted by one reviewer and confirmed by a second reviewer.RESULTS: A total of 424 abstracts were initially reviewed for inclusion, 66 manuscripts were reviewed for abstraction, and 4 studies were selected: one RCT and three cohort studies. The methods used to determine severity of illness varied: two studies (RCT and cohort study) used the ATS severity criteria, and two cohort studies used the pneumonia severity index. Short-term (in-hospital or 30-day) mortality varied between 4.2% to 67.3% for MT and 5.7% to 32.5% for CT. The RCT appeared to include a less severe spectrum of subjects since in-hospital mortality was < 6% versus 6% to 67% in the cohort studies.CONCLUSIONS: There appears to be considerable heterogeneity in the small number of studies of CT versus MT in SCAP.CLINICAL IMPLICATIONS: Further research is needed to examine the use of MT versus CT in patients with SCAP.
M.I. Restrepo, None.