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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In the updated 2020 guideline on community-acquired pneumonia&#44; Men&#233;ndez et al&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> still consider dual antibiotic therapy in all patients with community-acquired pneumonia &#40;CAP&#41;&#44; and also for outpatients&#46; Recommendations for CAP therapy should be different&#44; depending on whether patients require hospitalisation&#44; are admitted to intensive units or are treated as outpatients&#46; In line with the different recommendations published in other European countries&#44; Spanish guidelines in primary care recommend beta-lactam therapy in monotherapy as empirical treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Despite citing articles highlighting the little beneficial effect of macrolides in the treatment of outpatients with CAP&#44; Men&#233;ndez et al&#46; conclude that in the absence of randomised clinical trials and based on clinical evidence from observational studies&#44; the combination of a macrolide and a beta-lactam should constitute the empirical outpatient treatment regimen in patients with CAP or consider the administration of a quinolone in monotherapy&#46; However&#44; a recent systematic review and meta-analysis published by Horita et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> showed based on mostly observational studies that&#44; compared with beta-lactam monotherapy&#44; combination therapy with a beta-lactam plus macrolide may decrease all-cause mortality only in severe CAP&#44; with an odds ratio &#40;OR&#41; of 0&#46;75 &#40;95&#37; CI&#44; 0&#46;65&#8211;0&#46;86&#41;&#44; but not in mild to moderate CAP &#40;OR 1&#46;12&#44; 95&#37; CI&#44; 0&#46;87&#8211;1&#46;45&#41;&#46; However&#44; this pooled OR for mild to moderate CAP comes from only three studies&#58; two randomised clinical trials with patients with a median pneumonia severity index of 3 and one observational study &#40;outpatients with a low severity&#44; with a median CRB65 of 1&#41;&#46; No randomised clinical trials comparing beta-lactam with a combination of beta-lactam and macrolides have been published in primary care&#46; Extrapolation of the results of the group of mild to moderate CAP from this meta-analysis to patients managed in primary care might&#44; therefore&#44; not be straightforward&#46; However&#44; this is currently the only information available from patients with lower CAP severity&#46; The authors of this meta-analysis also found significantly more adverse events in the group receiving a combination of antibiotics&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Between two-thirds and 80&#37; of patients with CAP are treated as outpatients&#44; with a low therapeutic failure and a mortality rate of less than 1&#37;&#44; both in patients discharged from the emergency department or directly assessed in the primary care setting&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> There is compelling evidence that increasing consumption of antibiotics is associated with the development of antibiotic resistance&#44; both at the individual and the community level&#44; and increases the likelihood of adverse events&#44; as shown in the previous meta-analysis&#46; Therefore&#44; prudent antibiotic stewardship strategies&#44; aiming to ensure the judicious use of antimicrobials by preventing their unnecessary use&#44; should be encouraged&#46; In addition&#44; in the absence of a superiority of broad-spectrum antibiotic regimens&#44; narrowing the spectrum of coverage of empirical treatments as well as shortening the duration of therapies are preferable to reduce the emergence of resistance and adverse effects&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">We agree with the authors that more high quality randomised clinical trials comparing beta-lactam monotherapy with dual antibiotic regimens should be carried out in primary care&#46; However&#44; recommendations should be based on high quality clinical studies&#44; not on observational analyses&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> The few randomised clinical trials published so far do not show a clear benefit of adding macrolides to beta-lactams for the treatment of mild to moderate CAP&#46; Therefore&#44; we propose further studies in ambulatory CAP that allow us to reaffirm our idea that beta-lactam monotherapy should be the first line in outpatients and reserve respiratory fluoroquinolone or the combination of a macrolide and a beta-lactam if there is a documented allergy to &#946; lactams &#40;in this case use of fluoroquinolone&#41;&#44; presence of significant comorbidities&#44; therapeutic failure&#44; or in areas with high suspicion of prevalence of highly resistant pneumococci&#46; All this in order to reduce the antibiotic spectrum and therefore the risk of generating resistance&#46;</p></span>"
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Letter to the Editor
Dual Antibiotic Therapy for Outpatient Management of Community-acquired Pneumonia?
¿Tratamiento antibiótico dual en el manejo ambulatorio de la neumonía adquirida en la comunidad?
Carles Llora,b,
Corresponding author
carles.llor@gmail.com

Corresponding author.
, Ana Moragasc, Kristin Vevatnea
a University Institute in Primary Care Research Jordi Gol, Via Roma Health Centre, Barcelona, Spain
b Research Unit for General Practice, Department of Public Health, University of Copenhagen, Denmark
c Family doctor and associate professor, University Rovira i Virgili, Jaume I Health Centre, Tarragona, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In the updated 2020 guideline on community-acquired pneumonia&#44; Men&#233;ndez et al&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> still consider dual antibiotic therapy in all patients with community-acquired pneumonia &#40;CAP&#41;&#44; and also for outpatients&#46; Recommendations for CAP therapy should be different&#44; depending on whether patients require hospitalisation&#44; are admitted to intensive units or are treated as outpatients&#46; In line with the different recommendations published in other European countries&#44; Spanish guidelines in primary care recommend beta-lactam therapy in monotherapy as empirical treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Despite citing articles highlighting the little beneficial effect of macrolides in the treatment of outpatients with CAP&#44; Men&#233;ndez et al&#46; conclude that in the absence of randomised clinical trials and based on clinical evidence from observational studies&#44; the combination of a macrolide and a beta-lactam should constitute the empirical outpatient treatment regimen in patients with CAP or consider the administration of a quinolone in monotherapy&#46; However&#44; a recent systematic review and meta-analysis published by Horita et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> showed based on mostly observational studies that&#44; compared with beta-lactam monotherapy&#44; combination therapy with a beta-lactam plus macrolide may decrease all-cause mortality only in severe CAP&#44; with an odds ratio &#40;OR&#41; of 0&#46;75 &#40;95&#37; CI&#44; 0&#46;65&#8211;0&#46;86&#41;&#44; but not in mild to moderate CAP &#40;OR 1&#46;12&#44; 95&#37; CI&#44; 0&#46;87&#8211;1&#46;45&#41;&#46; However&#44; this pooled OR for mild to moderate CAP comes from only three studies&#58; two randomised clinical trials with patients with a median pneumonia severity index of 3 and one observational study &#40;outpatients with a low severity&#44; with a median CRB65 of 1&#41;&#46; No randomised clinical trials comparing beta-lactam with a combination of beta-lactam and macrolides have been published in primary care&#46; Extrapolation of the results of the group of mild to moderate CAP from this meta-analysis to patients managed in primary care might&#44; therefore&#44; not be straightforward&#46; However&#44; this is currently the only information available from patients with lower CAP severity&#46; The authors of this meta-analysis also found significantly more adverse events in the group receiving a combination of antibiotics&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Between two-thirds and 80&#37; of patients with CAP are treated as outpatients&#44; with a low therapeutic failure and a mortality rate of less than 1&#37;&#44; both in patients discharged from the emergency department or directly assessed in the primary care setting&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> There is compelling evidence that increasing consumption of antibiotics is associated with the development of antibiotic resistance&#44; both at the individual and the community level&#44; and increases the likelihood of adverse events&#44; as shown in the previous meta-analysis&#46; Therefore&#44; prudent antibiotic stewardship strategies&#44; aiming to ensure the judicious use of antimicrobials by preventing their unnecessary use&#44; should be encouraged&#46; In addition&#44; in the absence of a superiority of broad-spectrum antibiotic regimens&#44; narrowing the spectrum of coverage of empirical treatments as well as shortening the duration of therapies are preferable to reduce the emergence of resistance and adverse effects&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">We agree with the authors that more high quality randomised clinical trials comparing beta-lactam monotherapy with dual antibiotic regimens should be carried out in primary care&#46; However&#44; recommendations should be based on high quality clinical studies&#44; not on observational analyses&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> The few randomised clinical trials published so far do not show a clear benefit of adding macrolides to beta-lactams for the treatment of mild to moderate CAP&#46; Therefore&#44; we propose further studies in ambulatory CAP that allow us to reaffirm our idea that beta-lactam monotherapy should be the first line in outpatients and reserve respiratory fluoroquinolone or the combination of a macrolide and a beta-lactam if there is a documented allergy to &#946; lactams &#40;in this case use of fluoroquinolone&#41;&#44; presence of significant comorbidities&#44; therapeutic failure&#44; or in areas with high suspicion of prevalence of highly resistant pneumococci&#46; All this in order to reduce the antibiotic spectrum and therefore the risk of generating resistance&#46;</p></span>"
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Article information
ISSN: 03002896
Original language: English
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