Impact of macrolide therapy on clinical outcomes in hospitalized pneumonia patients: a retrospective study from Lebanese hospitals

Community-acquired pneumonia (CAP) poses a high burden on Lebanese hospitals, especially when patients require Intensive Care Unit (ICU) or prolonged length of stay. Macrolides are widely used for their antibacterial properties and also downregulate systemic inflammation. This retrospective cohort study examined 337 hospitalized patients with CAP in Lebanon between April 2011 and March 2025, comparing those who received macrolide with those who did not. Findings showed that, even after controlling for comorbidities, age, and inflammatory indicators, macrolide therapy was independently correlated with a significant reduction in mortality rate (adjusted OR = 0.26; p = 0.011). However, macrolides were not associated with reductions in ICU admission and length of stay. As for the inflammatory markers, levels of erythrocyte sedimentation rate (ESR), and procalcitonin (PCT) decreased significantly after macrolide treatment, but CRP did not. Subgroup analyses revealed fewer ICU admissions with azithromycin compared to clarithromycin, and with intravenous versus oral use, though these findings should be interpreted cautiously given the observational design. Overall, macrolide treatment, particularly azithromycin, may contribute to the improvement in survival of CAP patients, especially those with high inflammatory markers or comorbidities, which suggests potential benefit in using it in the context of a combination therapy. This result supports the rationale for using macrolides in combination therapy and emphasizes prospective studies to investigate their immunomodulatory properties in the management of pneumonia.