Is Activity against "Atypical" Pathogens Necessary in the Treatment Protocols for Community-Acquired Pneumonia? Issues with Combination Therapy
Is Activity against "Atypical" Pathogens Necessary in the Treatment Protocols for Community-Acquired Pneumonia? Issues with Combination Therapy
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DOI：
10.1086/591409
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发表时间：
2008-12-01
影响因子：
11.8
通讯作者：
Bartlett, John G.
中科院分区：
文献类型：
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作者：
Bartlett, John G.
综述的“非典型病原体”包括嗜肺军团菌、肺炎衣原体和肺炎支原体。尿抗原检测是军团菌最常用的检测方法，具有良好的特异性和合理的灵敏度。支原体在过去的十年中，免疫球蛋白M的检测大大提高了诊断特异性，并简化了测试。梭对于肺炎的诊断，对于可以普遍使用的简化测试没有共识，并且使用尚未很好地验证诊断准确性的测试的报告结果显示患病率存在很大差异。关于治疗试验，最近有3项荟萃分析讨论了使用或不使用针对非典型病原体的抗生素（大环内酯类或氟喹诺酮类与β-内酰胺类药物）的临床结局问题。这些分析还不能证明任何临床益处，除了在由L.嗜肺菌然而，20世纪50年代和60年代的多项研究支持四环素或红霉素治疗M.肺炎。对社区获得性肺炎住院患者抗生素治疗的最大非对照综述表明，与单独使用β-内酰胺类药物相比，使用大环内酯类联合头孢菌素类或氟喹诺酮类药物具有明显的获益，尽管这些数据支持非典型药物的潜在作用，因为其他潜在解释难以得出结论。关于未来的研究，值得注意的是，美国、加拿大和其他一些国家的标准治疗是常规使用药物治疗非典型病原体感染，这使得进行对照试验来解决这些问题在伦理上是困难的，实际上是不可能的。另外的局限性是C的诊断测试的困难。肺炎和快速治疗机构的重要性，患者病情严重到需要住院治疗。除了回顾性分析外，这些观察结果为特定药物的研究引入了实质性的伦理和后勤障碍。
The "atypical pathogens" reviewed include Legionella pneumophila, Chlamydophilia pneumoniae, and Mycoplasma pneumoniae. Urinary antigen tests are the most frequently used tests for Legionella species and show good specificity and reasonable sensitivity. For M. pneumoniae, detection of immunoglobulin M, used for the past decade, has substantially improved diagnostic specificity and has simplified testing. For C. pneumoniae, there is no consensus on a simplified test that can be commonly used, and the reported results, with the use of tests that have not been well validated for diagnostic accuracy, show great variation in prevalence. With regard to therapeutic trials, 3 meta-analyses have recently addressed the issue of clinical outcome with or without antibiotics directed against atypical pathogens (macrolides or fluoroquinolones vs. beta-lactam agents). These analyses have not been able to demonstrate any clinical benefit, except in a subset analysis of infections caused by L. pneumophila. Nevertheless, multiple studies from the 1950s and 1960s supported a clinical benefit of tetracycline or erythromycin treatment for infections caused by M. pneumoniae. The largest uncontrolled review of antibiotic treatment for hospitalized patients with community-acquired pneumonia demonstrated a clear benefit from the use of macrolides plus cephalosporins or fluoroquinolones, compared with the use of beta-lactams alone, although these data support a potential role for atypical agents, because other potential explanations make drawing conclusions difficult. With regard to future studies, it is noted that the standard of care in the United States, Canada, and some other countries is routine use of agents to treat infection with atypical pathogens, which makes the conduct of controlled trials to address these issues ethically difficult and practically impossible. Additional limitations are the difficulty in diagnostic testing for C. pneumoniae and the importance of rapid institution of therapy for patients severely ill enough to require hospitalization. These observations introduce substantial ethical and logistical barriers to studies of specific agents, except by retrospective analyses.