Are third-generation cephalosporins associated with a better prognosis than amoxicillin–clavulanate in patients hospitalized in the medical ward for community-onset pneumonia?

We aimed to assess whether treatment with ceftriaxone/cefotaxime is associated with lower in-hospital mortality than amoxicillin–clavulanate in pati0ents hospitalized in medical wards for community-onset pneumonia. We conducted a retrospective and multicentre study of patients hospitalized in French medical wards for community-onset pneumonia between 2002 and 2015. Treatments with ceftriaxone/cefotaxime or amoxicillin–clavulanate were defined by their start in the emergency department for a duration of 5 days or more with no other β-lactam. A logistic regression analysis was performed on the overall population, and a propensity score analysis was restricted to patients treated with either ceftriaxone/cefotaxime or amoxicillin–clavulanate. 1698 patients (median age, 80 y) were included, of which 716 and 198 were treated with amoxicillin–clavulanate and ceftriaxone/cefotaxime, respectively. In-hospital mortality was 10% (9–12%). In multivariate analysis, factors associated with in-hospital mortality were treatment with ceftriaxone/cefotaxime (aOR 2.9; (1.4–5.7)), pneumonia severity index class 4 or 5 (aOR 7.8 (4.3–15.7)), do-not-resuscitate order (aOR 8.7 (5.2–14.6)) and fluid therapy (aOR 6.3 (2.5–15.1)). The propensity score analysis was performed on 178 patients treated with ceftriaxone/cefotaxime matched with 178 patients treated with amoxicillin–clavulanate; no significant association between treatment with ceftriaxone/cefotaxime and in-hospital mortality was found (OR 1.5 (0.7–3.0)). In the largest study aiming to compare amoxicillin–clavulanate and ceftriaxone/cefotaxime in community-onset pneumonia, ceftriaxone/cefotaxime was not associated with lower in-hospital mortality than amoxicillin–clavulanate. Our results suggest that ceftriaxone/cefotaxime should not be preferred over amoxicillin–clavulanate for patients hospitalized in medical wards with community-onset pneumonia.