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SPECIAL ARTICLES: Review of Literature: General Infectious Diseases

SEVERE PNEUMONIA AND A SECOND ANTIBIOTIC

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Infectious Diseases in Clinical Practice: March-April 2002 - Volume 11 - Issue 3 - p 172-173
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SEVERE PNEUMONIA AND A SECOND ANTIBIOTIC

[Macfarlane J. Lancet 2002;359:1170]:

The author is the lead author on the British guidelines for management of community-acquired pneumonia (Thorax 2001;56 suppl 4: 1–64). Here he reviews the current recommendations for empiric treatment of severe community-acquired pneumonia from these guidelines as well as the ATS (Am J Respir Crit Care Med 2001;163:1730) and the IDSA (CID 2000;31:347). All three guidelines recommend the use of a betalactam combined with a macrolide or a betalactam combined with a fluoroquinolone. The controversial study that has recently appeared is by Grant Waterer et al. (Arch Intern Med 2001;161:1837). This report suggests that adults with severe bacteremic pneumococcal pneumonia have a 6.4-fold increase in death rate if given a single antibiotic rather than a combination of two or more on the day of admission. The potential explanations for the difference offered by Waterer included possible synergy, a possible alteration of the immune response by antibiotics and the possibility of co-pathogens such as C. pneumoniae or M. pneumoniae. Nevertheless, none of these mechanisms are strongly supported by existing data including the co-pathogen therapy which uses serologic tests for diagnosis that do not have clearly established scientific validity. Another possibility is that levofloxacin may be inferior as a single agent since failures have been reported (NEJM 2002;346:747), but the report by Waterer et al. showed as many deaths in those treated with third-generation cephalosporins and the largest study of pneumococcal bacteremia showed the lowest mortality with penicillin therapy (JID 2000; 182:840). The author concludes that there is no rational explanation for the difference that is clearly apparent, but the importance of pneumococcal pneumonia as a serious disease that requires the highest priority for empiric treatment needs to remain a high priority.

Comment:

It is difficult to disagree with the conclusion by Dr. Macfarlane, but it is even harder to passively accept the conclusions of the report by Waterer et al. until confirmed by additional studies.

© 2002 Lippincott Williams & Wilkins, Inc.