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Am Fam Physician. 2017;96(12):online

Clinical Question

For patients with confirmed influenza and an infiltrate consistent with pneumonia, does adding clarithromycin (Biaxin) and naproxen to oseltamivir (Tamiflu) improve outcomes?

Bottom Line

Adding clarithromycin and naproxen to oseltamivir significantly lowered all-cause mortality at 30 days and at 90 days. This study was limited by its open-label design. The outcome of mortality would not be subject to observer bias, though, and the groups were balanced. These findings are consistent with other studies of hospitalized patients with community-acquired pneumonia that concluded that adding a macrolide to amoxicillin/clavulanate (Augmentin) or a cephalosporin improves outcomes. (Level of Evidence = 1b)

Synopsis

These researchers recruited adults hospitalized with laboratory-confirmed influenza A (H3N2) within 72 hours of the onset of symptoms. All patients had an infiltrate on chest radiography, fever, and at least one typical symptom of influenza. Of 334 patients screened for inclusion, 217 were randomized to receive oseltamivir (75 mg twice daily), or oseltamivir plus clarithromycin (500 mg twice daily) and naproxen (200 mg twice daily). The oseltamivir was given for five days, whereas the naproxen and clarithromycin were given for three days. Groups were balanced at baseline. All patients also received amoxicillin/clavulanate and esomeprazole (Nexium). The mean age of patients was 80 years, and 57% were men. Approximately 50% were previously in good health, and despite extensive testing, only approximately 5% in each group had a bacterial coinfection.

All-cause mortality was significantly lower at 30 days in the group who received clarithromycin and naproxen (0.9% vs. 8.2%; P = .01; number needed to treat [NNT] = 14); it was also lower at 90 days (1.9% vs. 10%; P = .01; NNT = 13). The researchers hypothesized based on in vitro studies that naproxen and clarithromycin have antiviral properties, and they found that viral titers and the pneumonia severity index scores also declined faster in the combination therapy group. The median length of hospitalization was shorter for those in the combination therapy group (two vs. three days; P < .001), as was the likelihood of admission to the high-dependency unit, which is something between a regular ward and intensive care.

Study design: Randomized controlled trial (nonblinded)

Funding source: Government

Allocation: Concealed

Setting: Inpatient (any location)

Reference: HungIFNToKKWChanJFWet alEfficacy of clarithromycin-naproxen-oseltamivir combination in the treatment of patients hospitalized for influenza A(H3N2) infection: an open-label randomized, controlled, phase IIb/III trial. Chest2017;151(5):1069–1080.

POEMs (patient-oriented evidence that matters) are provided by Essential Evidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, see http://www.essentialevidenceplus.com. Copyright Wiley-Blackwell. Used with permission.

For definitions of levels of evidence used in POEMs, see http://www.essentialevidenceplus.com/product/ebm_loe.cfm?show=oxford.

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This series is coordinated by Sumi Sexton, MD, editor-in-chief.

A collection of POEMs published in AFP is available at https://www.aafp.org/afp/poems.

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