Moxifloxacin monotherapy versus β-lactam-based standard therapy for community-acquired pneumonia: a meta-analysis of randomised controlled trials

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Abstract

The aim of this study was to compare more conclusively the efficacy and safety of moxifloxacin, a new respiratory fluoroquinolone antibiotic, with β-lactam-based standard therapy, which has been reported to possess good efficacy for community-acquired pneumonia (CAP). A meta-analysis of randomised controlled trials (RCTs) identified in PubMed, the Cochrane Library and Embase was performed. Seven RCTs, involving 3903 patients, were included in the meta-analysis. Moxifloxacin monotherapy was associated with similar clinical treatment success rates [clinically evaluable population, odds ratio (OR) = 1.15, 95% confidence interval (CI) 0.81–1.64; intention-to-treat population, OR = 1.11, 95% CI 0.86–1.42] and similar mortality (OR = 0.98, 95% CI 0.66–1.46) compared with β-lactam-based standard therapy for CAP. Microbiological treatment success rates in the moxifloxacin group were significantly higher than in the β-lactam-based therapy group with a statistical margin (OR = 1.69, 95% CI 1.02–2.80). No difference was found regarding the incidence of adverse events and serious adverse events between moxifloxacin and β-lactam-based standard therapy. This meta-analysis provides evidence that moxifloxacin not only can be used as effectively and safely as β-lactam-based standard therapy for CAP but also possesses a favourable pathogen eradication rate. The once-daily dosing of moxifloxacin monotherapy may be a useful alternative for β-lactam-based standard therapy.

Introduction

Community-acquired pneumonia (CAP) is one of the leading causes of mortality and hospitalisation for all age groups throughout the world [1]. It is also the most frequent cause of community-acquired infections among patients admitted to intensive care units [2]. Because of the dramatically increased incidence of antibiotic resistance, particularly to β-lactams such as penicillin, in strains of Streptococcus pneumoniae over the past few years, treatment of CAP has become a challenge for clinicians [3], [4], [5].

The outcome of CAP depends on timely diagnosis and treatment involving appropriate antimicrobial therapy directed at the most common possible respiratory pathogens. β-Lactam-based therapy for CAP, such as the combination of a β-lactam and macrolide or β-lactamase inhibitor, covers the most common possible pathogens involved in the pathogenesis of CAP and acts as one of the first-line standard treatments [6]. Recently, respiratory fluoroquinolones with enhanced activity against S. pneumoniae were introduced in the treatment of CAP.

Moxifloxacin, a new respiratory fluoroquinolone antibiotic that acts by inhibiting bacterial topoisomerases II and IV, not only possesses increased activity against typical (notably S. pneumoniae), atypical and anaerobic respiratory pathogens, but also has enhanced potential to minimise the emergence of bacterial resistance [7], [8], [9], [10], [11], [12], [13], [14], [15], [16]. Several randomised controlled trials (RCTs) have been performed to compare the efficacy of moxifloxacin with β-lactam-based therapy for CAP [17], [18], [19], [20], [21], [22], [23]. The results mainly suggest that moxifloxacin is at least as effective as β-lactam-based therapy. However, these results were not completely consistent and did not necessarily justify that moxifloxacin monotherapy was as effective as all the standard β-lactam-based therapies. Aiming to compare more conclusively the efficacy and safety of moxifloxacin with β-lactam-based regimens for the treatment of CAP, we undertook a systematic review with meta-analysis of relevant RCTs.

Section snippets

Data sources

This study was performed using a pre-specified search strategy and study eligibility criteria. An extensive search of PubMed (up to December 2009), the Cochrane Central Register of Controlled Trials (up to Cochrane Library Issue 4, 2009) and Embase (1980 to December 2009) was performed to identify relevant RCTs for the meta-analysis. The search was restricted to RCTs. Search term combinations were ‘moxifloxacin’, ‘β-lactams’ and ‘community-acquired pneumonia’. The language of the research

Study selection process

The flow diagram in Fig. 1 shows the detailed screening and selection process applied before including trials in the meta-analysis. The search was performed in PubMed, the Cochrane Central Register of Controlled Trials and Embase. Eleven full papers from 63 studies were obtained for detailed evaluation. Seven RCTs involving 3903 patients were ultimately identified that fulfilled all of the criteria for inclusion in the meta-analysis.

Study characteristics

The main characteristics of the seven included RCTs (type of

Discussion

This systematic review with meta-analysis compared the efficacy and safety of moxifloxacin monotherapy with that of β-lactam-based standard therapy for CAP patients. This meta-analysis indicates that moxifloxacin monotherapy was associated with similar overall rates of clinical cure and mortality and with higher bacteriological success rates compared with β-lactam-based therapy (Fig. 2, Fig. 3). The safety analysis regarding the incidence of adverse events proved no difference between the

Acknowledgment

The current authors are indebted to the authors of the primary studies, without whose contributions this work would not have been possible.

Funding: No funding sources.

Competing interests: None declared.

Ethical approval: Not required.

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    These authors contributed equally to this paper.

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