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Letter to the Editor
Reply to “Dual antibiotic therapy for outpatient management of community-acquired pneumonia?”
Respuesta a «Dual antibiotic therapy for outpatient management of community-acquired pneumonia?»
Rosario Menéndeza,b,
Corresponding author
rosmenend@gmail.com

Corresponding author.
, Raúl Méndeza, Antoni Torresb,c
a Servicio de Neumología, Hospital Universitario y Politécnico La Fe, Valencia, Spain
b CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
c Servicio de Neumología, Hospital Clínic, Barcelona, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">One of the most controversial topics in the recommendations and consensus documents on antibiotic treatment in respiratory infections is the choice of outpatient treatment of pneumonia&#46; The debate between monotherapy with a beta-lactam or combination with a macrolide leads to differences of opinion among clinicians&#44; and even among scientific societies&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> There is some logic to the arguments&#44; and several reasons to justify both approaches in the treatment of mild pneumonia&#46; The first and most important is that no randomized trials with sufficient patient numbers have been conducted in different geographical areas and over long periods that include different seasons&#44; comparing the use of a beta-lactam alone versus the combination of a beta-lactam with a macrolide&#46; The few studies in non-hospitalized patients use mortality as a study variable&#44; which is unhelpful since death rates are very low in this setting&#44; and it is unlikely that significant differences will be detected&#46; Other outcomes&#44; such as therapeutic failure&#44; complications or need for later admission&#44; would be of greater interest&#46; Secondly&#44; because microbiological studies are not performed&#44; there is a shortage of etiological information in mild pneumonia&#44; so the percentage of intracellular microorganisms in which macrolides play an obvious role is unknown&#46; The few studies that use microbiological molecular diagnostic techniques show that the prevalence of these intracellular bacteria&#44; in particular <span class="elsevierStyleItalic">Legionella pneumophila</span>&#44; is underestimated&#46; Moreover&#44; in the early stages of infection&#44; urinary antigen testing for <span class="elsevierStyleItalic">Legionella pneumophila</span> may give false negatives&#44; and this technique also only recognizes serotype <span class="elsevierStyleSmallCaps">i</span>&#46; In Spain<span class="elsevierStyleItalic">&#44; Legionella pneumophila</span> occurs in up to 6&#37; of cases in the outpatient setting and a beta-lactam in monotherapy is insufficient&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Microbiological point-of-care testing in the outpatient setting that covers a range of bacteria and viruses would be very useful for improving etiological information&#59; however&#44; we are aware that these services are not available in standard practice and conventional microbiological studies are not recommended in the guidelines&#46; The third factor is the possibility of pneumonia caused by mixed etiologies such as pneumococcus and intracellular bacteria or the possibility of bacteremia in mild pneumonias&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> For all these reasons&#44; the therapeutic approach to mild pneumonias should always include a regimen offering complete cover that always includes pneumococcus and intracellular bacteria&#44; in order to reduce the chance of failure&#46; Efforts must be made to avoid continuing the macrolide for more than 3 or 5 days if the response is good&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Horita et al&#46; published a meta-analysis<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> analyzing the impact of the combination of beta-lactams and macrolides on mortality&#44; but only 3 studies were included in the mild&#47;moderate pneumonia subgroup&#46; This is insufficient to properly address mortality&#44; and the authors recognize the shortage of randomized and observational studies in their paper&#46; Asadi et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> in an observational study of 2&#44;845 patients&#44; compared macrolides with quinolones&#44; and found fewer hospital admissions and lower mortality &#40;0&#46;2 vs&#46; 3&#46;0&#37;&#44; p&#8239;&#61;&#8239;0&#46;02&#41; in the macrolide group&#46; In fact&#44; macrolides have even shown good outcomes in patients with risk factors for pneumococcal resistance&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">When the decision has to be made between using fewer antibiotics or offering complete coverage of the most common microorganisms of mild pneumonia&#44; the SEPAR update of the CAP guidelines leans towards the second option&#46; We agree that a very large&#44; well-designed randomized trial may provide an answer to this unresolved issue&#46;</p></span>"
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Article information
ISSN: 15792129
Original language: English
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