Risk of SARS-CoV-2 reinfection after natural infection.
Risk of SARS-CoV-2 reinfection after natural infection.
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DOI：
10.1016/s0140-6736(21)00662-0
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发表时间：
2021-03-27
期刊：
影响因子：
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通讯作者：
Altmann DM
中科院分区：
文献类型：
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作者：
Boyton RJ;Altmann DM
大量患者可以安全地接受3天的抗生素治疗。然而，在治疗第3天评估合格性的706例患者中，仅310例符合随机化条件。在被排除的396人中，许多人有限制在任何卫生保健环境中使用短期治疗的原因：122人临床不稳定，80人患有严重或复杂的社区获得性肺炎，22人无家可归或有其他原因意味着他们无法密切随访，80人患有晚期肾衰竭。对照组治疗8天的原因尚不清楚，而大多数专家建议因无并发症的社区获得性肺炎住院的患者治疗5天。未提供该队列中社区获得性肺炎病因的数据，这是一个特别值得关注的问题，因为在社区获得性肺炎患者中报告了高病毒感染率。9由于许多轻度疾病患者可能有非细菌性原因，因此抗生素无论持续多久都不太可能影响其结果。事实上，在基线时测量降钙素原水平的安慰剂组50例患者和β-内酰胺组57例患者中，β-内酰胺组的降钙素原水平低于安慰剂组（0· 20 μmol/L vs 0· 55 μmol/L），这意味着β-内酰胺组更多的患者可能患有非细菌性疾病，因此没有真实的机会从延长治疗中获益。6理想情况下，治疗持续时间的研究应该只包括那些细菌或非典型病原体感染的患者。然而，Dinh及其同事的研究中使用的β-内酰胺单药治疗（美国指南推荐β-内酰胺加大环内酯联合治疗或氟喹诺酮单药治疗）未涵盖非典型病原体，并且可能掩盖了与治疗持续时间相关的任何差异。根据本研究的数据，我们认为对于因社区获得性肺炎住院的患者，不建议常规治疗3天。我们认为应该进行一项使用当前双盲随机设计的关键特征的研究，但使用更多重病患者，使用检查疾病原因的数据，排除那些没有记录的细菌或非典型病原体感染，并考虑β-内酰胺加大环内酯和氟喹诺酮类药物的治疗方案。MSN报告了Shionogi的赠款和个人费用，Bayer，Nabriva，和Paratek以外的工作领域在这里评论;并已咨询费舍尔诊断对肺炎的抗菌药物管理的主题。LAM报告了默克、Daiichi-Sankyo、Sunovion和Covance在此处评论的工作领域之外的个人费用。
substantial group of patients who can safely be treated with 3 days of antibiotics. However, of the 706 patients assessed for eligibility on day 3 of therapy, only 310 were eligible for randomisation. Of the 396 who were excluded, many had reasons that would restrict the use of short duration therapy in any health-care setting: 122 were not clinically stable, 80 had severe or complicated community-acquired pneumonia, 22 were homeless or had other reasons that meant they could not be followed up closely, and 80 had advanced renal failure. Why the comparator group was treated for 8 days is unclear, when 5 days are recommended by most experts for patients admitted to hospital with uncomplicated communityacquired pneumonia. No data were provided on the cause of community-acquired pneumonia in this cohort, which is of specific interest because a high prevalence of viral infections has been reported in patients with community-acquired pneumonia. 9 Since many patients with mild illness might have had a non-bacterial cause, it is unlikely that antibiotics, of any duration, could affect their outcome. In fact, among the 50 patients in the placebo group and 57 in the β-lactam group who had procalcitonin levels measured at baseline, those in the β-lactam group had lower levels than those in the placebo group (0· 20 μmol/L vs0· 55 μmol/L), implying that more patients in the β-lactam group might have had non-bacterial illness and thus no real chance to benefit from extended therapy. 6 Ideally, a study of the duration of therapy should have included only those with bacterial or atypical pathogen infection. However, monotherapy with a β-lactam, as used in Dinh and colleagues’ study (US guidelines recommend either a β-lactam plus macrolide combination or fluoroquinolone monotherapy), provides no coverage for atypical pathogens, and could have masked any differences related to duration of therapy. On the basis of the data from this study, we do not feel that 3 days of treatment can be recommended routinely for patients admitted to hospital for communityacquired pneumonia. We feel that a study using the key features of the current double-blind randomised design should be done, but with more seriously ill patients, with data examining cause of illness, excluding those without documented bacterial or atypical pathogen infection, and taking into account both β-lactam plus macrolide and fluoroquinolone based treatment regimens.MSN reports grants and personal fees from Shionogi, personal fees from Bayer, Nabriva, and Paratek outside of the area of work commented on here; and has consulted for Fisher Diagnostics on the topic of antimicrobial stewardship of pneumonia. LAM reports personal fees from Merck, Daiichi-Sankyo, Sunovion, and Covance outside of the area of work commented on here.