A prospective, randomized, multicenter trial of azithromycin versus cefuroxime plus erythromycin for community-acquired pneumonia in hospitalized patients

Azithromycin is a newer macrolide antibiotic with in vitro activity against both typical and atypical pathogens. The ATS guidelines suggest that either a cephalosporin or a beta-lactam /beta-lactamase inhibitor (+/-erythromycin) be the initial, empiric therapy for community-acquired pneumonia in hospitalized patients. 148 evaluable patients with community-acquired pneumonia were enrolled. Randomization was stratified by age and severity of illness. Each patient received extensive testing for atypical pathogens, including PCR, serology, culture, and urinary antigen. The experimental regimen was iv azithromycin (500mg qd) followed by oral azithromycin (500mg qd). The ATS regimen was iv ceturoxime (750 mg q8h) followed by oral cefiiroxime axetil (500mg q12h), plus erythromycin (500mg-1000mg iv or po qid, if atypical pathogens were suspected). Immunosuppressed patients were excluded. The overall clinical efficacy rates for azithromycin vs cefuroxime plus erythromycin were identical (91%). For bacteremic pneumococcal pneumonia, clinical efficacy rates for azithromycin vs the ATS regimen were 67% (2/3) and 75% (3/4), respectively. No differences were statistically significant. 3 patients died, but no deaths were attributed to antibiotic failure. In summary, azithromycin as monotherapy was as effective as the ATS regimen of ceruroxime plus erythromycin in the treatment of community-acquired pneumonia.