Journal club

Abstract

The ACCESS trial ( Lancet Respir Med 2024;12(4):294–304) provides new evidence supporting the use of macrolides in community-acquired pneumonia (CAP). In this prospective, double-blind study, Giamarellos-Bourboulis and colleagues randomised patients admitted with CAP and receiving intravenous antibiotics to addition of either oral clarithromycin or placebo for 7 days. Participants from 18 Greek hospitals were enrolled, with CAP defined as consolidation on chest radiograph with compatible auscultatory findings or consolidation on CT, though a pathogen was only identified in 55% of the study population (most commonly Staphylococcus aureus ). Inclusion criteria limited the study to a subset of hospital patients with systemic inflammation, requiring two positive criteria of systemic inflammatory response syndrome, a sequential organ failure assessment (SOFA) score of≥2, and a procalcitonin of≥0.25 ng/mL. The primary outcome was achievement at day 4 of both an ‘early clinical response’ (≥50% decrease in respiratory symptom score) and an ‘early inflammatory response’ (≥30% decrease in SOFA score and/or procalcitonin decrease by≥80% or to<0.25 ng/mL). This endpoint was met in 68% (n=91) of patients treated with clarithromycin, compared with 38% (n=51) in the placebo group (OR 3.40 (95% CI 2.06 to 5.63), p<0.0001). Secondary analyses revealed that clarithromycin significantly reduced the rate of progression to organ dysfunction and recurrent sepsis, and shortened time to hospital …