Kantonsspital Olten, SWITZERLAND;
Swiss Med Wkly. 2013 Sep 19;143:w13870. doi: 10.4414/smw.2013.13870. eCollection 2013.
Although most experts recommend empirical antibiotic treatment, covering also atypical bacteria, for patients admitted to an intensive care unit (ICU), the data are not clear for patients admitted to a general ward. European guidelines recommend starting empirical treatment with a beta-lactam antibiotic with or without a macrolide, but the with/without is not clarified. We investigated whether the use of antibiotic coverage for atypical pathogens was guided by clinical parameters.
We retrospectively analysed 300 patients hospitalised with community-acquired pneumonia. Four parameters for possible atypical pneumonia (age <55 years, abdominal symptoms, sodium <130 mmol/l, immunosuppression) and three for pneumonia severity (pneumonia severity index [PSI], ICU admission, pO2 <8 kPa (60 mm Hg) or O2 saturation <90%) were defined and correlated with the probability of coverage for atypical pathogens. Correlations were calculated using the chi-square test for 2 x 2 tables.
Patients younger than 55 years significantly more likely to receive coverage for atypical pathogens than older patients (odds ratio [OR] 2.68; 95% confidence interval [CI] 1.3-5.5, p = 0.009). In patients with a PSI >III the proportion receiving coverage for atypical bacteria was even smaller than in patients with less severe pneumonia (OR 0.77; 95% CI 0.60-0.99, p = 0.03), but no difference was found for PSI >IV compared with PSI ≤IV (OR = 1.03; 95% CI 0.61-1.74, p = 0.9). The other clinical parameters had no effect on antibiotic coverage: ICU admission (OR =1.39; 95% CI 0.87-2.4, p = 0.15); pO2 >8 kPa or O2-Saturation >90% (OR 1.36; 95% CI 0.85-2.17, p = 0.19); abdominal symptoms (OR 1.06; 95% CI 0.51-2.25, p = 0.88); sodium <130 mmol/l (OR 0.63; 95% CI 0.29-1.36, p = 0.2) or immunosuppression (OR 1.007; 95% CI 0.462-44, p = 1). There was also no correlation between the number of clinical parameters present and the coverage of atypical pathogens (r = 0.48). Mortality was no different between patients in whom atypical pathogens were covered compared with those with beta-lactam therapy alone (OR 1.2; 95% CI 0.66-2.25, p = 0.43).
Physicians have difficulties deciding when to cover atypical pathogens in hospitalised patients with community-acquired pneumonia. Guidelines should clarify under what circumstances combination therapy is warranted.
尽管大多数专家建议对入住重症监护病房（ICU）的患者进行经验性抗生素治疗，包括覆盖非典型细菌，但对于入住普通病房的患者，数据尚不清楚。欧洲指南建议使用β-内酰胺类抗生素联合或不联合大环内酯类药物进行经验性治疗，但联合/不联合并未明确。我们研究了是否根据临床参数指导使用抗生素覆盖非典型病原体。
我们回顾性分析了 300 名因社区获得性肺炎住院的患者。我们定义了四个可能为非典型肺炎的参数（年龄<55 岁、腹部症状、血清钠<130mmol/L、免疫抑制）和三个肺炎严重程度的参数（肺炎严重指数[PSI]、入住 ICU、pO2<8kPa（60mmHg）或氧饱和度<90%），并将其与非典型病原体覆盖的可能性相关联。使用卡方检验计算 2x2 表的相关性。
年龄<55 岁的患者比年龄较大的患者更有可能接受非典型病原体的覆盖治疗（优势比[OR]2.68；95%置信区间[CI]1.3-5.5，p=0.009）。PSI>III 的患者接受非典型细菌覆盖治疗的比例甚至比肺炎严重程度较轻的患者更小（OR 0.77；95%CI 0.60-0.99，p=0.03），但与 PSI>IV 相比，PSI≤IV 患者之间没有差异（OR=1.03；95%CI 0.61-1.74，p=0.9）。其他临床参数对抗生素覆盖没有影响：入住 ICU（OR=1.39；95%CI 0.87-2.4，p=0.15）；pO2>8kPa 或氧饱和度>90%（OR 1.36；95%CI 0.85-2.17，p=0.19）；腹部症状（OR 1.06；95%CI 0.51-2.25，p=0.88）；血清钠<130mmol/L（OR 0.63；95%CI 0.29-1.36，p=0.2）或免疫抑制（OR 1.007；95%CI 0.462-44，p=1）。存在的临床参数数量与非典型病原体的覆盖之间也没有相关性（r=0.48）。与接受β-内酰胺单药治疗的患者相比，接受非典型病原体覆盖治疗的患者的死亡率没有差异（OR 1.2；95%CI 0.66-2.25，p=0.43）。
医生在决定何时对因社区获得性肺炎住院的患者覆盖非典型病原体时存在困难。指南应明确在何种情况下需要联合治疗。
