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Published ahead of print on March 1, 2007, doi:10.1164/rccm.200603-350OC
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American Journal of Respiratory and Critical Care Medicine Vol 175. pp. 1086-1093, (2007)
© 2007 American Thoracic Society
doi: 10.1164/rccm.200603-350OC

Original Article

A Worldwide Perspective of Atypical Pathogens in Community-acquired Pneumonia

Forest W. Arnold1, James T. Summersgill1, Andrew S. LaJoie1,2, Paula Peyrani1, Thomas J. Marrie3, Paolo Rossi4, Francesco Blasi5, Patricia Fernandez6, Thomas M. File, Jr.7, Jordi Rello8, Rosario Menendez9, Lucia Marzoratti10, Carlos M. Luna11, Julio A. Ramirez1 and the Community-Acquired Pneumonia Organization (CAPO) Investigators*

1 Division of Infectious Diseases, Department of Medicine, and 2 Department of Health Promotion and Behavioral Sciences, University of Louisville, Louisville, Kentucky; 3 University of Alberta Hospital, Sturgeon Community Hospital, Grey Nuns Hospital, and Royal Alexandra Hospital, Edmonton, Alberta, Canada; 4 Department of Medicine, S. Maria della Misericordia Hospital, Udine, Italy; 5 Istituto Malattie Respiratorio, University of Milan, Istituto di Ricerca e Cura a Carattere Scientifico, Policlinico, Milan, Italy; 6 Instituto Nacional del Torax, Santiago, Chile; 7 Summa Health System, Akron, Ohio; 8 Joan XXIII University Hospital, Tarragona, Spain; 9 Hospital Universitario La Fe, Valencia, Spain; 10 Sanatorio 9 de Julio, Tucuman, Argentina; and 11 Hospital de Clinicas, Buenos Aires, Argentina

Correspondence and requests for reprints should be addressed to Forest W. Arnold, D.O., Division of Infectious Diseases, University of Louisville, Carmichael Building, Room 208E, 512 South Hancock Street, Louisville, KY 40292. E-mail: f.arnold{at}louisville.edu

Rationale: Controversy still exists in the international literature regarding the need to use antimicrobials covering atypical pathogens when initially treating hospitalized patients with community-acquired pneumonia (CAP). In different regions of the world, monotherapy with a beta-lactam antimicrobial is common.

Objectives: We sought to correlate the incidence of CAP due to atypical pathogens in different regions of the world with the proportion of patients treated with an atypical regimen in those same regions. In addition, we sought to compare clinical outcomes of patients with CAP treated with and without atypical coverage.

Methods: A secondary analysis was performed using two comprehensive international databases. World regions were defined as North America (I), Europe (II), Latin America (III), and Asia and Africa (IV). Time to reach clinical stability, length of hospital stay, and mortality were compared between patients treated with and without atypical coverage.

Measurements and Main Results: The incidence of CAP due to atypical pathogens from 4,337 patients was 22, 28, 21, and 20% in regions I–IV, respectively. The proportion of patients treated with atypical coverage from 2,208 patients was 91, 74, 53, and 10% in regions I–IV, respectively. Patients treated with atypical coverage had decreased time to clinical stability (3.7 vs. 3.2 d, p < 0.001), decreased length of stay (7.1 vs. 6.1 d, p < 0.01), decreased total mortality (11.1 vs. 7%, p < 0.01), and decreased CAP-related mortality (6.4 vs. 3.8%, p = 0.05).

Conclusions: The significant global presence of atypical pathogens and the better outcomes associated with antimicrobial regimens with atypical coverage support empiric therapy for all hospitalized patients with CAP with a regimen that covers atypical pathogens.

Key Words: pneumonia, mycoplasma • pneumonia, pneumococcal • atypical • community-acquired infection • empiric antibiotic


AT A GLANCE COMMENTARY

Scientific Knowledge on the Subject
American Thoracic Society guidelines for community-acquired pneumonia recommend the use of antimicrobials covering atypical pathogens in all hospitalized patients, but some studies do not show a benefit.

What This Study Adds to the Field
Atypical pathogens are common causes of community-acquired pneumonia in all regions of the world. Treatment regimens including coverage for atypical pathogens are associated with improved patient outcome.

 



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