Published ahead of print on March 1, 2007, doi:10.1164/rccm.200603-350OC
Am. J. Respir. Crit. Care Med., Volume 175, Number 10, May 2007, 1086-1093
A more recent version of this article appeared on May 15, 2007
Submitted on March 9, 2006
Accepted on February 26, 2007
A Worldwide Perspective of Atypical Pathogens in Community-Acquired Pneumonia
Forest W Arnold1*, James T Summersgill1, Andrew S LaJoie2, Paula Peyrani1, Thomas J Marrie3, Paolo Rossi4, Francesco Blasi5, Patricia Fernandez6, Thomas M File, Jr7, Jordi Rello8, Rosario Menendez9, Lucia Marzoratti10, Carlos M Luna11, Julio A Ramirez1, and CAPO Investigators12
1 University of Louisville, Division of Infectious Diseases, Louisville, KY, USA,
2 University of Louisville, Division of Infectious Diseases, Louisville, KY, USA; Department of Health Promotion and Behavioral Sciences, University of Louisville, Louisville, KY, USA,
3 University of Alberta Hospital, Sturgeon Community Hospital, Grey Nuns Hospital and Royal Alexandra Hospital, Edmonton, AL, Canada,
4 Department of Medicine, S. Maria della Misericordia Hospital, Udine, Italy,
5 IRCCS, Milano, Italy,
6 Instituto Nacional del Torax, Santiago, Chile,
7 Summa Health System, Akron, OH, USA,
8 Joan XXIII University Hospital, Tarragona, Spain,
9 Hospital Universitario La Fe, Valencia, Spain,
10 Sanatorio 9 de Julio, Tucuman, Argentina,
11 Hospital de Clinicas, Buenos Aires, Argentina,
12 See appendix, none
* To whom correspondence should be addressed. 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 (I)North America, (II)Europe, (III)Latin America, (IV)Asia and Africa. Time to reach clinical stability, length of hospital stay (LOS), 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 days, P<0.001), decreased LOS (7.1 vs. 6.1 days, P<0.01), decreased total mortality (11.1% versus 7%, P<0.01), and decreased CAP-related mortality (6.4% versus 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
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