Kolditz Martin, Halank Michael, Höffken Gert
Department of Pulmonology, Medical Clinic I, University Hospital Carl Gustav Carus, Dresden, Germany.
Treat Respir Med. 2006;5(6):371-83. doi: 10.2165/00151829-200605060-00002.
Current international guidelines for the management of community acquired pneumonia (CAP) recommend therapy with a beta-lactam plus a macrolide or a 'respiratory' fluoroquinolone alone in patients hospitalized in a medical ward, and combination therapy with a beta-lactam plus a macrolide or a fluoroquinolone in patients hospitalized in the intensive care unit. However, which of the available options should be preferred remains a matter of debate, and there are surprisingly few prospective randomized trials strictly comparing mono- versus dual therapy strategies in CAP patients. Thus, the recommendation of combining a macrolide with a beta-lactam rather than using a beta-lactam alone in hospitalized patients is derived mainly from observational data, and the suggested combination of a beta-lactam with a fluoroquinolone in severe CAP has been rarely examined in a clinical trial.As there have been sound theoretical arguments for and against combination therapy regimens, the rationale for the different options is discussed and available clinical trial data are reviewed in this article. A final conclusion about the superiority of one antibacterial regimen over another in hospitalized patients with CAP cannot be drawn on the basis of the limited data available. So far, combination therapy probably should be preferred in all patients presenting with severe pneumonia, whereas in general, combination therapy is not necessary in patients in a medical ward, and combination therapy with a beta-lactam plus a macrolide or monotherapy with a respiratory fluoroquinolone should be considered equivalent in this latter patient group. On the other hand, the available data demonstrate that empirical coverage of atypical bacteria in all patients with mild-to-moderate CAP seems unnecessary, and beta-lactam monotherapy might perform equally well when compared with respiratory fluoroquinolones in patients with non-severe CAP. Thus, the alternative use of a beta-lactam alone at adequate dosage in clinically stable patients seems justified, if CAP due to Legionella pneumophila is unlikely.
当前社区获得性肺炎（CAP）管理的国际指南建议，在内科病房住院的患者中使用β-内酰胺类药物联合大环内酯类药物或单独使用“呼吸喹诺酮类”药物进行治疗，而在重症监护病房住院的患者中使用β-内酰胺类药物联合大环内酯类药物或喹诺酮类药物进行联合治疗。然而，哪种可用方案更优仍存在争议，令人惊讶的是，严格比较CAP患者单药治疗与联合治疗策略的前瞻性随机试验很少。因此，住院患者中推荐将大环内酯类药物与β-内酰胺类药物联合使用而非单独使用β-内酰胺类药物，主要是基于观察性数据，而在严重CAP中建议的β-内酰胺类药物与氟喹诺酮类药物的联合使用在临床试验中很少被研究。由于对于联合治疗方案存在合理的支持和反对的理论依据，本文将讨论不同方案的基本原理并回顾现有的临床试验数据。基于有限的数据，无法得出一种抗菌方案在住院CAP患者中优于另一种的最终结论。到目前为止，对于所有出现严重肺炎的患者，联合治疗可能更可取，而一般来说，在内科病房的患者中联合治疗并非必要，在后者这组患者中，β-内酰胺类药物联合大环内酯类药物的联合治疗或使用呼吸喹诺酮类药物的单药治疗应被视为等效。另一方面，现有数据表明，对所有轻至中度CAP患者进行非典型细菌的经验性覆盖似乎没有必要，在非严重CAP患者中，与呼吸喹诺酮类药物相比，β-内酰胺类单药治疗可能同样有效。因此，如果不太可能是嗜肺军团菌引起的CAP，在临床稳定的患者中单独使用足够剂量的β-内酰胺类药物似乎是合理的。
