Efficacy of Doxycycline for Mild-to-moderate Community-acquired Pneumonia in Adults: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND: Doxycycline has been recommended as a treatment option for non-severe community-acquired pneumonia (CAP) in adults. We sought to review the evidence for the efficacy of doxycycline in adult patients with mild-to-moderate CAP. METHODS: We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) of doxycycline versus comparator to assess the clinical efficacy. The primary outcome was the clinical cure rate. Random effects model meta-analyses were used to generate pooled odds ratio (OR) and evaluate heterogeneity (I2). Risk of bias (RoB) and quality of evidence (QoE) were evaluated using the Cochrane Risk of Bias 2.0 tool and GRADE methods, respectively. RESULTS: We included six RCTs with 834 clinically evaluable patients. The trials were performed between 1984 and 2004. Comparators were three macrolides (roxithromycin, spiramycin, and erythromycin) and three fluoroquinolones (ofloxacin, fleroxacin, and levofloxacin). Four trials had an overall high RoB. The clinical cure rate was similar between the doxycycline and comparator groups (87.2% [381/437] vs. 82.6% [328/397]; OR 1.29 [95% CI: 0.73-2.28]; I2 = 30%; low QoE). Subgroup analysis of two studies with a low RoB showed significantly higher clinical cure rates in the doxycyline group (87.1% [196/225] vs. 77.8% [165/212]; OR 1.92 [95% CI: 1.15-3.21]; P = 0.01; I2 = 0%). Adverse event rates were comparable between the doxycycline and comparator groups. CONCLUSION: The efficacy of doxycycline was comparable to macrolides or fluoroquinolones in mild-to-moderate CAP and thus represents a viable treatment option. Considering the lack of recent trials, it warrants large-scale clinical trials