Keys T F
Department of Infectious Disease, Cleveland Clinic Foundation, OH 44106.
Semin Respir Infect. 1987 Dec;2(4):270-3.
Selection of therapy for legionella infections originated with the clinical observation after the 1976 Philadelphia outbreak that patients treated with erythromycin or tetracycline did better than those who received cephalosporins or aminoglycosides. Early in vitro antibiotic susceptibility studies suggested that rifampin and erythromycin were both active against Legionella pneumophila. However, subsequent in vitro susceptibility studies to other antibiotics have produced variable results, depending on the medium and methodology used. Antibiotic studies within polymorphonuclear leukocytes and alveolar macrophages indicate that those actively concentrated within these cells are predictive of successful therapy. These include erythromycin, rifampin, and certain quinolones. On the other hand, beta-lactam antibiotics such as penicillin, cefoxitin, and imipenem are less likely to be successful because of their lack of concentration within phagocytes. These observations have been confirmed in animal model studies where erythromycin, rifampin, and quinolones have demonstrated efficacy. The addition of rifampin to erythromycin or to doxycycline may be more effective than therapeutic results with either antibiotic alone. Although erythromycin is presently the treatment of choice for legionellosis, the addition of rifampin is recommended, particularly in immunocompromised patients. Doxycycline has served as an appropriate alternative agent, the newer quinolones may be useful and are deserving of carefully designed clinical trials.
军团菌感染治疗方法的选择源于1976年费城疫情后的临床观察，即接受红霉素或四环素治疗的患者比接受头孢菌素或氨基糖苷类药物治疗的患者情况更好。早期的体外抗生素敏感性研究表明，利福平和红霉素对嗜肺军团菌均有活性。然而，随后对其他抗生素的体外敏感性研究结果不一，这取决于所使用的培养基和方法。在多形核白细胞和肺泡巨噬细胞内进行的抗生素研究表明，那些能在这些细胞内有效聚集的抗生素预示着治疗会成功。这些抗生素包括红霉素、利福平以及某些喹诺酮类药物。另一方面，β-内酰胺类抗生素，如青霉素、头孢西丁和亚胺培南，由于它们在吞噬细胞内缺乏聚集，治疗成功的可能性较小。这些观察结果在动物模型研究中得到了证实，在这些研究中，红霉素、利福平以及喹诺酮类药物都显示出了疗效。将利福平与红霉素或强力霉素联合使用可能比单独使用任何一种抗生素的治疗效果更好。虽然目前红霉素是治疗军团病的首选药物，但建议加用利福平，尤其是对于免疫功能低下的患者。强力霉素是一种合适的替代药物，新型喹诺酮类药物可能也有用，值得进行精心设计的临床试验。
