To the Editors:
We read with interest the recent paper by Restrepo et al. 1 who reported that adding a macrolide to the antibiotic regimen in patients with community-acquired pneumonia (CAP) and severe sepsis resulted in lower mortality. Their data are very promising. However, we have a concern regarding the recommendations to implement macrolides as standard treatment for CAP.
Treatment with macrolides has been shown to have beneficial effects in chronic inflammatory airway diseases such as diffuse panbronchiolitis 2 and cystic fibrosis 3. Whether adding macrolide therapy to the antibiotic regimen in patients with sepsis and CAP will result in a better outcome cannot be concluded from the study performed by Restrepo et al. 1. Their nonrandomised study did not provide information regarding clinical decisions such as why some patients were given macrolide therapy and others were not. Moreover, we are not informed about the presence of infections caused by Legionella pneumophila type 1 which are relatively common in patients with severe CAP 4. Adding macrolide therapy is one of the choices of treatment in infections caused by this microorganism.
The conclusion of Restrepo et al. 1 recommended further prospective studies. In 2005, we published a prospective randomised study in which we compared a pathogen-directed therapy, based on monotherapy, with an empirical approach consisting of a betalactam antibiotic and a macrolide in patients with CAP 5. In that study, we showed that both treatment regimes resulted in comparable efficacy. In patients with severe CAP who were referred to the intensive care unit, combination treatment, including a macrolide and a betalactam antibiotic, resulted in a significantly higher mortality rate. Although this group of patients was relatively small, we are not convinced that adding macrolide therapy to patients with CAP will result in the same beneficial effects as seen in chronic inflammatory airway diseases such as cystic fibrosis and diffuse panbronchiolitis, unless atypical pathogens sensitive for macrolide therapy are present. Concerning the increasing rate of microbial resistance due to antibiotic overuse, we need to be very careful when deciding to add macrolide therapy for immunomodulation reasons in patients with CAP.
Statement of interest
None declared.
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