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Immunocompromised patients are the most likely to gain from enhanced
bactericidal activity possibly offered by lactam-aminoglycoside combination
therapy.9 In a comparison of lactam monotherapy with lactam-aminoglycoside
combination therapy restricted to patients with neutropenia we found no
advantage to combination treatment.89 Although the approach to the
management of patients with and without neutropenia is separated in clinical
practice, this similarity supports a biological basis underlying our
results. Antibiotic treatment is nearly always instituted empirically and
is often continued with no isolate to direct specific treatment. Most trials
assessed this scenario and do not support a benefit for combination therapy.
Clinicians may still opt for combination empirical treatment to increase the
probability of appropriate empirical treatment, which has indeed been shown
to improve survival.90 91 Current evidence suggests that aminoglycoside
monotherapy may be inadequate for infections outside the urinary tract.10 92
93 Thus, for the purpose of enhancing antimicrobial spectrum,
aminoglycosides may constitute a poor choice. Combination treatment is
considered for patients with severe infections. However, these are the
patients most prone to harm by the addition of an aminoglycoside. With no
proved survival benefit, combination therapy may be unjustifiable. Several
studies, included in the overall and subgroup analyses, directly assessed
semiempirical combination versus monotherapy. These, similarly, do not
support combination therapy for specific pathogens, when detected.
