Therapy for pneumococcal bacteremia: monotherapy or combination therapy?

The issue of whether the outcome of bacteremic pneumococcal infections is improved with the use of combination antibiotic therapy versus monotherapy is still not resolved. This review highlights recent studies that have addressed this issue.

Some studies have indicated benefit of combination antibiotic therapy in severely ill patients with community-acquired pneumonia of all-cause. Conversely, in less severely ill hospitalized patients, fluoroquinolone monotherapy was as effective as fluoroquinolone combination regimens and a propensity analysis failed to show benefit of beta-lactam/macrolide combination over beta-lactam monotherapy. Studies across the world have shown a more favorable outcome in patients with community-acquired pneumonia treated with guideline-compliant therapy, mostly beta-lactam/macrolide combination regimens. The only recent study of patients with bacteremic pneumococcal pneumonia failed, however, to show benefit of combination therapy. A large number of investigations have yielded observations that address possible mechanisms by which combination therapy may have benefit, investigating issues such as cover for atypical pathogens, attenuation of pneumococcal virulence factors, and anti-inflammatory activity of the macrolide group of antibiotics.

Despite a number of recent studies, the definitive decision regarding the need for combination antibiotic therapy for the effective management of bacteremic pneumococcal infections has not yet been formally resolved.