Doxycycline Alone for Mild to Moderate Community Acquired Pneumonia?

Reviewed by Erica Stohs, MD, MPH, University of Nebraska

Doxycycline is a recommended treatment for non-severe community acquired pneumonia (CAP) in the ATS/IDSA CAP guidelines, though most providers do not select it as monotherapy due to concern for pneumococcal tetracycline resistance. This systematic review and meta-analysis sought to review the evidence for the efficacy of doxycycline in adult patients with mild-to-moderate CAP.

Authors included 6 RCTs with 834 comparable patients between 1984 and 2004. Comparators were 3 macrolides (roxithromycin, spiramycin, and erythromycin) and 3 fluoroquinolones (ofloxacin, fleroxacin, and levofloxacin). The primary outcome was the clinical cure rate, defined as the resolution of clinical signs and symptoms at the end of treatment or follow-up, no recurrence of symptoms, no complication, and no additional antibiotics. Though several secondary outcomes were sought, only adverse events were available to compare.

The clinical cure rate was similar between the doxycycline and comparator groups: 87.2% [381/437] vs 82.6% [328/397]. Adverse event rates were comparable between the doxycycline and comparator groups. They also analyzed risk of bias (4 RCTs had high ROB) and quality of evidence. Overall, this study may widen providers’ antibiotic arsenal for treating non-severe CAP, particularly in patients with contraindications to traditionally sought-after regimens, such as confirmed beta-lactams allergies or prolonged QT, or as an alternative to the C. diff-provoking quinolones. As always, providers need to consult their local antibiogram for pneumococcal susceptibility patterns.

The commentary affiliated with this article by Dan Musher (member of the ATC/IDSA CAP committee and wasn’t a fan of doxycycline monotherapy) put this study into historical and clinical context. This previous doxy-nay-sayer is more willing to consider it for mild-moderate CAP.


  • Choi S, et al. “Efficacy of Doxycycline for Mild-to-Moderate Community-Acquired Pneumonia in Adults: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.” CID 2023;76(4):683–91.
  • Musher D. “Doxycycline to Treat Community-Acquired Pneumonia.” CID 2023;76(4):692–693.
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