Community-acquired pneumonia: oral antibiotics are as effective as intravenous for uncomplicated cases

Clinical bottom line (level 1b)

  1. Patients with a lower respiratory tract infection who take oral co-amoxiclav compared with intravenous cephalosporins are more likely to be cured (NNT = 10 at unknown) .
  2. Patients treated with oral co-amoxiclav are not less likely to be cured than patients treated with intravenous co-amoxiclav.
  3. There is no clear effect on mortality.
Chan et al: British Medical Journal 1995; 310: 1360-1362
Expires March 2003

The study

Unblinded ?concealed randomised trial with intention-to-treat
Setting: acute hospital, Ireland

541 patients (aged mean 64, 52% female) admitted with a lower respiratory tract infection (new or increasing cough productive of sputum and associated with other symptoms and signs of chest infection including dypnoea, wheeze, chest pain or focal or diffuse signs on chest examination or radiography; and one or more constitutional symptoms including fever, sweating, headache and aches and pains)

Excluded if
  • pregnant or lactating women
  • unable to tolerate oral medication
  • acute confusion
  • multilobar disease seen on chest X-ray
  • immunocompromised - HIV or neutropenia
  • allergic to penicillin or cephalosporins
  • critically-ill patients requiring admission to intensive care or requiring inotropic or respiratory support
  • clinical or laboratory evidence of septicaemia


    • Control Group: (n = 179, 179 analysed): co-amoxiclav 1.2 g iv three times a day for 3 days followed by 375 mg by mouth three times a day for 4 days
    Experimental Group: (n = 181, 181 analysed): cefotaxime 1g iv three times a day for 3 days followed by cefuroxime 500 mg by mouth twice a day
    Experimental Group: (n = 181, 181 analysed): co-amoxiclav 375 mg by mouth three times a day for 7 days

    100% followed for ? length of hospital stay
    Outcome notes:
    • cure or partial cure : improvement in symptoms enough to allow hospital discharge, and no further course of antibiotics required

    The evidence

    oral co-amoxiclav v. iv co-amoxiclav
    Outcome Time to outcome CEREERRRR
    (95% CI)    		ARR
    (95% CI)    		NNT
    (95% CI)
    cure or partial cure unknown 129
    (71.3%)    		 142
    (78.5%)    		 10%
    (-2% to 24%)    		 7.18%
    (-1.72% to 16.1%)    		 14
    (NNT = 6 to infinity;
    NNH = 58 to infinity)
    death unknown 13
    (7.18%)    		 9
    (4.97%)    		 31%
    (-58% to 70%)    		 2.21%
    (-2.71% to 7.13%)    		 45
    (NNT = 14 to infinity;
    NNH = 37 to infinity)

    oral co-amoxiclav v. iv cephalosporins
    Outcome Time to outcome CEREERRRR
    (95% CI)    		ARR
    (95% CI)    		NNT
    (95% CI)
    cure or partial cure unknown 122
    (68.2%)    		 142
    (78.5%)    		 15%
    (1% to 31%)    		 10.3%
    (1.22% to 19.4%)    		 10
    (5 to 82)
    death unknown 11
    (6.15%)    		 9
    (4.97%)    		 19%
    (-91% to 61%)    		 1.17%
    (-3.56% to 5.91%)    		 85
    (NNT = 17 to infinity;
    NNH = 28 to infinity)

    Comments

    1. The study definition of LRTI may include patients with acute bronchitis, which does not respond to antibiotics, and may overestimatethe benefit of oral co-amoxiclav

    Citation

    1. Chan R, Hemeryck L, O'Regan M, et al: oral versus intravenous antibiotics for community acquired lower respiratory tract infection in a general hospital: open, randomised controlled trial. British Medical Journal 1995; 310: 1360-1362
    Contributor: Chris Ball and Clare Wotton, November 1999
    Reviewer: Mituhiro Kamei

    Clinical Question.
    Patient lower respiratory tract infection
    Intervention or Exposure oral antibiotics
    Comparison intravenous antibiotics
    Outcome cure, death, mortality