Reply to Chalmers et al.
Reply to Chalmers et al.
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回复查尔默斯等人。
DOI：
10.1093/cid/ciw466
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发表时间：
2016
期刊：
影响因子：
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通讯作者：
Grijalva,CarlosG
中科院分区：
文献类型：
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作者：
Self,WesleyH;Wunderink,RichardG;Williams,DerekJ;Waterer,GrantW;Jain,Seema;Edwards,KathrynM;Grijalva,CarlosG
致编辑-我们感谢查尔默斯等人[1]强调了我们关于葡萄球菌社区获得性肺炎（CAP）研究的几个重要方面，该研究最近发表在临床传染病[2]上。我们同意万古霉素大量用于经验性治疗许多住院的CAP患者，这些患者的耐甲氧西林金黄色葡萄球菌（MRSA）感染风险较低。此外，我们同意在美国胸科学会和美国传染病学会最近的肺炎指南中将医疗相关性肺炎（HCAP）作为抗MRSA治疗的适应症[3]可能导致了抗MRSA抗生素的大量使用。我们并不打算暗示所有入住重症监护室（ICU）的CAP患者都应凭经验使用抗MRSA抗生素进行治疗。相反，ICU患者中MRSA的患病率为2.7%，并且这些MRSA感染的ICU患者的结局特别严重，我们认为我们的数据支持选择性而不是普遍使用抗MRSA抗生素治疗ICU患者。我们主张在决定是否启动经验性抗MRSA覆盖时对个别ICU患者进行深思熟虑的临床评估，并迅速获得高质量的标本进行病原学检测，包括尽可能的下呼吸道标本。不幸的是，没有精确的指南来帮助临床判断是否开始抗MRSA抗生素[4]。当根据经验开始使用抗MRSA抗生素时，当第一轮病原学检测结果返回时，通常可以安全地停止使用[5]。不幸的是，在更快速的检测方法出现之前，由于对MRSA肺炎这种罕见但危及生命的疾病的担忧，抗MRSA抗生素的过度治疗可能会继续下去。因此，我们强烈主张开发更好的快速诊断工具，以确定肺炎的病因。在CAP和医院获得性肺炎的诊断之间，存在着来自社区的近期医疗暴露的广泛患者，这些患者不适合任何一类。HCAP范例将这些“介于”患者与医院获得性肺炎组中的大多数混为一谈[3]。为了纳入更广泛的患者，其中一些患者可能存在耐药病原体的风险，我们在研究中对CAP进行了更广泛的定义，并招募了几类符合“HCAP标准”的患者，即接受长期血液透析的患者、肺炎出现前30-90天住院的免疫功能正常的患者、一些免疫抑制患者和独立功能的疗养院居民[2，6]。然而，我们确实排除了具有某些临床特征的患者，这些临床特征使他们处于多重耐药病原体的高风险中，包括严重的免疫抑制，
TO THE EDITOR—We thank Chalmers et al [1] for highlighting several important aspects of our study on staphylococcal community-acquired pneumonia (CAP), recently published in Clinical Infectious Diseases [2]. We agree that vancomycin is heavily used for empirical treatment of many hospitalized patients with CAP who have a low risk of methicillinresistant Staphylococcus aureus (MRSA) infection. Furthermore, we agree that inclusion of healthcare-associated pneumonia (HCAP) as an indication for anti-MRSA therapy in recent pneumonia guidelines from the American Thoracic Society and Infectious Disease Society of America [3] has probably contributed to the heavy use of anti-MRSA antibiotics. We did not intend to imply that all patients with CAP admitted to an intensive care unit (ICU) should be treated empirically with anti-MRSA antibiotics. Rather, with a MRSA prevalence of 2.7% among ICU patients and particularly severe outcomes for these MRSA-infected ICU patients, we believe our data support selective rather than universal treatment of ICU patients with anti-MRSA antibiotics. We advocate for a thoughtful clinical assessment of individual ICU patients when deciding whether to initiate empirical anti-MRSA coverage and for the rapid obtainment of high-quality specimens for etiologic testing, including lower respiratory tract specimens whenever possible. Unfortunately, precise guidelines are not available to assist clinical judgment on whether to start anti-MRSA antibiotics [4]. When anti-MRSA antibiotics are empirically started, they can frequently be safely stopped when results of the initial round of etiologic testing return [5]. Until more rapid testing becomes available, overtreatment with anti-MRSA antibiotics is, unfortunately, likely to continue out of concern for the rare but life-threatening condition of MRSA pneumonia. Hence, we strongly advocate developing better rapid diagnostic tools to determine the cause of pneumonia.Between the diagnoses of CAP and hospital-acquired pneumonia lie a wide spectrum of patients presenting from the community with recent healthcare exposure who do not fit well into either category. The HCAP paradigm lumps most of these “between” patients with the hospital-acquired pneumonia group [3]. To include a broader spectrum of patients, some of whom may have been at risk for resistant pathogens, we defined CAP more broadly in our study and enrolled several classes of patients with “HCAP criteria,” namely, those receiving long-term hemodialysis, immunocompetent patients hospitalized 30–90 days before their pneumonia presentation, some immunosuppressed patients, and independently functioning nursing home residents [2, 6]. However, we did exclude patients who had certain clinical features placing them at high risk for multidrugresistant pathogens, including severe immunosuppression, hospitalization in the