Quinolones are employed in the treatment of nosocomial pneumonia (NP) because of their favorable pharmacodynamic and safety profiles. Although effective in vitro against pathogens responsible for NP, few clinical trials exploring the use quinolones in NP have been reported. We sought to provide more comprehensive data regarding quinolones in NP.
We conducted a meta-analysis of randomized, controlled trials (RCTs) studying quinolones for NP. We identified citations through a systematic literature search and had no language restrictions. We excluded trials that did not utilize a currently commercially available quinolone (e.g., clinafloxacin). We extracted data regarding pathogens isolated, use of combination gram-negative therapy, and severity of illness. Clinical cure represented our primary endpoint; mortality and emergence of resistance among Pseudomonal species served as secondary endpoints.
We identified 5 RCTs that included 1186 subjects. The median Jadad quality score was 6; only one trial was blinded. Four studies employed ciprofloxacin (all using 400 mg IV every 8 hrs) while one studied levofloxacin (750 mg IV QD). For the comparator agent 3 investigations relied on imipenem/cilistatin, 1 used ceftazadime, and 1 left the choice to the physician. Only three RCTs reported severity of illness (APACHE II score range: 13.8±7.5 to 17.7±6.5). The incidence of P. aeruginosa in these the trials varied widely (3.4%-34.7%) as did the use of combination gram-negative therapy (0%-58.3%). For both clinical cure and mortality, quinolones performed similarly to comparator agents (odds ratio for cure: 1.1, 95% CI: 0.8-1.6, odds ratio for mortality 0.9, 95% CI: 0.6-1.4). In the 3 reports tracking resistance among Pseudomonas spp., the lowest rate of emergence of resistance was seen with levofloxacin (5.8%).
Quinolones perform comparably to other standard regimens for NP. The often used ciprofloxacin regimen of 400 mg IV Q12 hrs has not been prospectively studied.
Quinolones are an acceptable part of a treatment regimen for NP. No head-to-head clinical trial data suggest one quinolone is superior to another for NP.
A.F. Shorr, None.