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Original research
Empiric antibiotics for community-acquired pneumonia in adult patients: a systematic review and a network meta-analysis
  1. Lara Montes-Andujar1,
  2. Elena Tinoco1,
  3. Orville Baez-Pravia2,
  4. Carlos Martin-Saborido3,4,
  5. Pablo Blanco-Schweizer5,
  6. Carmen Segura5,
  7. Estefania Prol Silva5,
  8. Vivivan Reyes6,
  9. Ana Rodriguez Cobo1,
  10. Carmen Zurdo7,
  11. Verónica Angel1,
  12. Olga Varona1,
  13. José Valero1,
  14. Rafael Suarez del Villar1,
  15. Guillermo Ortiz8,
  16. Julio Villanueva1,
  17. Justo Menéndez1,
  18. Jesús Blanco5,9,
  19. Antoni Torres10,11,
  20. Pablo A Cardinal-Fernández2
  1. 1 Emergency Department, Hospital Universitario HM Sanchinarro, Madrid, Spain
  2. 2 Intensive Care Unit, Hospital Universitario HM Sanchinarro, Madrid, Spain
  3. 3 Escuela Nacional de Sanidad (ENS), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
  4. 4 Centro de educación superior Hygiea, UDIMA, Madrid, Spain
  5. 5 Intensive Care Unit, Rio Hortega University Hospital, Valladolid, Castilla y León, Spain
  6. 6 Intensive Care Unit, Universidad del Bosque, Bogota, Colombia
  7. 7 Emergency Department, Hospital Universitario HM Sanchinarro, Madrid, Madrid, Spain
  8. 8 Universidad El Bosque, Bogota, Colombia
  9. 9 Biomedical Research Center Network for Respiratory Diseases (CIBERES), ISCIII, Madrid, Spain
  10. 10 UVIR, Hospital Clínic, Barcelona, Catalunya, Spain
  11. 11 Biomedical Research Center Network for Respiratory Diseases (CIBERES), Madrid, Spain
  1. Correspondence to Dr Pablo A Cardinal-Fernández, Intensive Care Unit, Hospital Universitario HM Sanchinarro, Madrid 28050, Spain; pablocardinal{at}


Objective The main aim of this network meta-analysis is to identify the empiric antibiotic (Em-ATB) with the highest probability of being the best (HPBB) in terms of (1) cure rate and (2) mortality rate in hospitalised patients with community acquired pneumonia (CAP) .

Method Inclusion criteria: (1) adult patients (>16 years old) diagnosed with CAP that required hospitalisation; (2) randomised to at least two different Em-ATBs, (3) that report cure rate and (4) are written in English or Spanish. Exclusion criteria: (1) ambiguous antibiotics protocol and (2) published exclusively in abstract or letter format. Data sources: Medline, Embase, Cochrane and citation reviews from 1 January 2000 to 31 December 2018. Risk of bias: Cochrane’s tool. Quality of the systematic review (SR): A MeaSurement Tool to Assess systematic Reviews-2. Certainity of the evidence: Grading of Recommendations Assessment, Development and Evaluation. Statistical analyses: frequentist method performed with the ‘netmeta’ library, R package.

Results 27 randomised controlled trials (RCTs) from the initial 41 307 screened citations were included. Regarding the risk of bias, more than one quarter of the studies presented low risk and no study presented high risk in all domains. The SR quality is moderate. For cure, two networks were constructed. Thus, two Em-ATBs have the HPBB: cetaroline 600 mg (two times a day) and piperacillin 2000 mg (two times a day). For mortality, three networks were constructed. Thus, three Em-ATBs have the HPBB: ceftriaxone 2000 mg (once a day) plus levofloxacin 500 (two times a day), ertapenem 1000 mg (two times a day) and amikacin 250 mg (two times a day) plus clarithromycin 500 mg (two times a day). The certainity of evidence for each results is moderate.

Conclusion For cure rate, ceftaroline and piperaciline are the options with the HPBB. However, for mortality rate, the options are ceftriaxone plus levofloxacin, ertapenem and amikacin plus clarithromycin. It seems necessary to conduct an RCT that compares treatments with the HPBB for each event (cure or mortality) (CRD42017060692).

  • pneumonia
  • clinical epidemiology
  • emergency medicine
  • respiratory infection

Data availability statement

Data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request.

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  • AT and PAC-F are joint senior authors.

  • Twitter @CMSaborido, @cardinalpablo

  • Contributors Idea, study design, results analysis and manuscript writing: JM, JB, AT and PAC-F. Data retrieval, results analysis and manuscript writing: LM-A, ET, OB-P, CM-S, PB-S, EPS, VR, ARC, CZ, VA, OV, JV, RSdV, GO, JV, JM, JB, AT, PAC-F.

  • Funding SGR 2017/787, Ciber de Enfermedades Respiratorias (Ciberes CB06/06/0028), Pneumonia Corporate Research Program (CRP). The Ciberes is an iniciative of the ISCIII. SGR: Support to research groups of Catalunya.

  • Competing interests AT declared that belong to the advisory board of Pfizer, MSD, biomerieux, Menarini and Chiesi. In addition, reports fees from Pfizer and MSD.

  • Provenance and peer review Not commissioned; externally peer reviewed.