Impact of initial antibiotic choice on mortality from pneumococcal pneumonia

Monotherapy versus combination antibiotic therapy for patients with bacteremic Streptococcus pneumoniae community-acquired pneumonia

The purpose of this study was to examine the impact of antimicrobial monotherapy vs combination therapy on length of stay and mortality for patients with Streptococcus pneumoniae pneumonia. Thirty-nine percent of patients received monotherapy, while 61% received combination therapy. Although there was no significant difference in mortality (OR 1.25, 95% CI = 0.25-6.8), there was a significant increase in length of stay for patients who received combination therapy (p = 0.02). Patients with bacteremic pneumococcal pneumonia treated with empiric combination therapy had no significant difference in mortality; however, they did have increased length of stay after adjusting for severity of illness. Randomized controlled trials are needed to determine what is the optimal empiric antimicrobial regime for patients with community-acquired pneumonia.

Therapie der ambulant erworbenen Pneumonie

The S3 guidelines for diagnosis and therapy use German epidemiological data to set the standards for a risk and degree of severity based treatment of community acquired pneumonia (CAP). Over the last few years, a change in pathogen epidemiology has been recognized with the significance of staphylococci and enterobacteria increasing. CAP is becoming increasingly a disease of the elderly, for whom a more broadly effective initial therapy appears to be needed. Resistant pathogens play an important role in the course of the disease. For patients with a low risk of mortality, a reduction in the length of therapy seems possible. On the other hand, the early identification of critically ill patients who require treatment with high dose, broad spectrum antibiotics is necessary. Antibiotic associated diarrhoea, caused by Clostridium difficile, is a significant complication in antibiotic therapy. With the introduction of vaccination against Streptococcus pneumoniae for children, a change in the course of the illness and an improvement in the resistance situation has been achieved. An update of the S3 guidelines is intended for 2008 in order to integrate new knowledge into the recommendations.

Healthcare Epidemiology: Does Antibiotic Selection Impact Patient Outcome?

Inadequate antibiotic therapy, generally defined as microbiologically ineffective anti-infective therapy against the causative pathogen, can influence patient outcome. However, the detrimental effects of inadequate antibiotic therapy seem to become weaker in the most severely ill patients with short life expectancies. In addition to severity of illness, other methodological issues should be carefully examined in studies assessing the excess mortality due to inadequate therapy. To adjust for confounding as much as possible in order to obtain an unbiased estimate of the magnitude of the effect of inadequate therapy is a key methodological challenge for future research. With regard to the choice of antibiotic agents, beta-lactam and aminoglycoside combination therapy does not seem to improve clinical outcome in most cases of sepsis caused by gram-negative bacteria, including Pseudomonas aeruginosa bacteremia. A potential benefit of combination therapy in the treatment of severe pneumococcal sepsis has been suggested in several observational studies, but recently published data have disputed this hypothesis. Finally, better risk scores and laboratory tools are urgently needed to improve the adequacy of empirical antibiotic therapy and patient outcomes.

Controversies in the treatment of pneumococcal community-acquired pneumonia

Community-acquired pneumonia remains an important cause of disease and death both in the developed and the developing worlds, despite the ready availability of potent antimicrobial agents to which the organisms remain susceptible. Furthermore, disease management is complicated by emerging resistance of the common pathogens to the various classes of commonly prescribed antimicrobial agents. Much recent research in the field of community-acquired pneumonia has focused attention on optimal treatment, evaluating the impact of antibiotic resistance, as well as of antimicrobial choices, on the outcome of these infections. In addition, efforts have been directed towards finding adjunctive therapies to antibiotics that may improve the prognosis of these patients. This article reviews some of these research areas, highlighting controversies that still exist with regard to final recommendations, and in particular with regard to infections with Streptococcus pneumoniae, the most common bacterial cause of community-acquired pneumonia.

[Pneumonia awareness year, 2004: scientific impact through publications in Archivos de Bronconeumología]

Pneumonia is a common and potentially serious infectious disease. Morbidity and mortality rates continue to be high in spite of major advances and steady progress in diagnosis and treatment. The economic impact of the disease is also great. It is therefore necessary to enlist the public, primary care and emergency physicians, and public policy administrators to join forces to treat and prevent pneumonia for the common good. The annual incidence of pneumonia in the population over the age of 14 years is 1.6 to 2.6 episodes/1000 inhabitants. The mortality rate is 14.1 per 100,000 inhabitants, and the associated costs are 115 million euros annually. The RESPIRA Foundation and the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) declared 2004 to be pneumonia awareness year with the aim of coordinating efforts to raise awareness, distribute information, and foster debate.

Monotherapy versus Combination Therapy in Patients Hospitalized with Community-Acquired Pneumonia

Current international guidelines for the management of community acquired pneumonia (CAP) recommend therapy with a beta-lactam plus a macrolide or a 'respiratory' fluoroquinolone alone in patients hospitalized in a medical ward, and combination therapy with a beta-lactam plus a macrolide or a fluoroquinolone in patients hospitalized in the intensive care unit. However, which of the available options should be preferred remains a matter of debate, and there are surprisingly few prospective randomized trials strictly comparing mono- versus dual therapy strategies in CAP patients. Thus, the recommendation of combining a macrolide with a beta-lactam rather than using a beta-lactam alone in hospitalized patients is derived mainly from observational data, and the suggested combination of a beta-lactam with a fluoroquinolone in severe CAP has been rarely examined in a clinical trial.As there have been sound theoretical arguments for and against combination therapy regimens, the rationale for the different options is discussed and available clinical trial data are reviewed in this article. A final conclusion about the superiority of one antibacterial regimen over another in hospitalized patients with CAP cannot be drawn on the basis of the limited data available. So far, combination therapy probably should be preferred in all patients presenting with severe pneumonia, whereas in general, combination therapy is not necessary in patients in a medical ward, and combination therapy with a beta-lactam plus a macrolide or monotherapy with a respiratory fluoroquinolone should be considered equivalent in this latter patient group. On the other hand, the available data demonstrate that empirical coverage of atypical bacteria in all patients with mild-to-moderate CAP seems unnecessary, and beta-lactam monotherapy might perform equally well when compared with respiratory fluoroquinolones in patients with non-severe CAP. Thus, the alternative use of a beta-lactam alone at adequate dosage in clinically stable patients seems justified, if CAP due to Legionella pneumophila is unlikely.