Mortality and clinical cure rates for pneumonia: A systematic review, meta-analysis, and trial sequential analysis of randomized control trials comparing bactericidal and bacteriostatic antibiotic treatments.

Bactericidal antibiotics are generally assumed to be superior to bacteriostatic antibiotics as first-line treatment for pneumonia.We performed a systematic review, meta-analysis, and trial sequential analysis (TSA) of randomized controlled trials of bactericidal versus bacteriostatic antibiotics to ascertain clinical outcomes.We conducted a systematic review to identify all randomized control trials (RCTs) comparing the use of bacteriostatic and bactericidal antibiotics in the treatment of bacterial pneumonia. A meta-analysis and trial sequential analysis (TSA) was performed with clinical cure rate as the primary outcome. Secondary outcomes included all-cause mortality, microbiological eradication, treatment failure and relapse rates. Data sources included PubMed, Cochrane Library, Embase and MedRxiv. Data on dichotomous outcomes were presented as Risk Ratio (RR). A random-effects model with the generic Mantel-Haenszel method was used for integrating Risk Ratio (RRs) for generalizability of findings. The I-squared method was used to assess the magnitude of variation secondary to heterogeneity.Forty-three RCTs involving 10,752 patients met the eligibility criteria. Clinical cure rate [42 studies (10312 patients) RR 1.02 (95% Cl, 0.99-1.05); I2 37%; TSA-adjusted CI 0.99-1.05], all-cause mortality [25 studies (8302 patients) RR 1.07 (95% CI, 0.81-1.42); I2 57%], microbiological eradication [ 24 studies (2776 patients) RR 1.00 (95% Cl, 0.97-1.03); I2 0%], treatment failure [31 studies (7296 patients) RR 0.96 (95% Cl, 0.83-1.11); I2 42%], and relapse rate [5 studies(1111 patients) RR 1.15 (95% Cl, 0.50-2.63); I2 0%] were similar between bactericidal and bacteriostatic antibiotic treatments.Bactericidal agents are not associated with any statistical difference in clinical cure rates, mortality, microbiological eradication, treatment failure or relapse rates compared to bacteriostatic antibiotics in the treatment of pneumonia.CRD42021257094.