Emerging treatments

Coenzyme Q10

Coenzyme Q10 is a naturally occurring, fat-soluble, vitamin-like quinone that may be beneficial in people aged >60 years with CAP when given as an adjunct to antibiotic treatment. Results from a small (n=141) randomised controlled trial showed a significantly faster decline in fever, shorter hospital stays, and less treatment failure in patients with CAP receiving coenzyme Q10 (200 mg/day) compared with those receiving placebo when given for 14 days together with antibiotic therapy (prescribed according to latest guidelines).[203] Adverse events in the two groups were few and similar. CAP was diagnosed according to defined clinical and radiological criteria. It is not clear, however, whether this study had enough power to detect any meaningful differences between groups, and therefore no recommendations can be made until further evidence is available. 

Omadacycline

A new modernised tetracycline antibiotic with broad-spectrum activity, designed to overcome tetracycline resistance. It is approved by the US Food and Drug Administration for the treatment of adults with CAP. It is available in oral and intravenous formulations, and is expected to be available commercially in early 2019. Like other antibiotics in the tetracycline class, omadacycline may cause discolouration of deciduous teeth, and inhibition of fetal bone growth when administered during pregnancy.

Ceftaroline

Ceftaroline is a fifth-generation parenteral extended-spectrum cephalosporin that binds to penicillin-binding proteins and prevents the synthesis of the bacterial cell wall. It has antimicrobial activity against gram-positive organisms, including Streptococcus pneumoniae, Streptococcus pyogenes, Staphylococcus aureus (including methicillin-resistant S aureus [MRSA], vancomycin-resistant S aureus [VRSA], and hetero-resistant vancomycin intermediate S aureus [hVISA]), as well as many common gram-negative organisms, such as Haemophilus influenzae andMoraxella catarrhalis. Reviews have found that ceftaroline is superior to ceftriaxone in patients with CAP in terms of clinical cure rates.[204][205]

Ceftobiprole

Ceftobiprole is a broad-spectrum parenteral cephalosporin that has microbiological activity against most typical bacterial pathogens causing CAP, including MRSA. A phase III study found that ceftobiprole was non-inferior to ceftriaxone with or without linezolid for the treatment of CAP.[206]

Nemonoxacin

A non-fluorinated, broad-spectrum quinolone. It has greater antimicrobial activity than the fluoroquinolones (e.g., levofloxacin) against MRSA, methicillin-sensitive Staphylococcus epidermidis (MSSE), methicillin-resistant S epidermidis (MRSE), S pneumoniae, and Enterobacter faecalis. A phase II study found that nemonoxacin has high clinical cure rates in adults with CAP.[207]

Solithromycin

A fluoroketolide with antimicrobial activity against gram-positive and gram-negative bacteria commonly associated with CAP. A completed phase II study showed that solithromycin had similar efficacy to that of levofloxacin in adults with bacterial CAP with pneumonia severity index scores of II to IV.[208] It has also been found to be non-inferior to moxifloxacin.[209] Solithromycin is currently in phase III development for the treatment of bacterial CAP.

Cethromycin

A fluoroketolide with a reported high antimicrobial activity against gram-positive and gram-negative bacteria, and atypical pathogens (including Mycoplasma and Ureaplasma). It also has in vitro activity against penicillin-resistant and macrolide-resistant gram-positive organisms, possibly due to a high affinity for the target site on the ribosomal unit.[210]

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