Efficacy of Empiric Antibiotic Coverage in Community-Acquired Pneumonia Associated with Each Atypical Bacteria: A Meta-Analysis.

Khalid Eljaaly,Abrar K Thabit,Thamer A Almangour,Ali A Rabaan,Mohannad Alshibani,Ahmed Aljabri,Ohoud Aljuhani

doi:10.3390/jcm10194321

Abstract

The benefit of empiric coverage for community-acquired pneumonia (CAP) for atypical bacteria is controversial. This meta-analysis purpose was to compare the clinical failure rate between adults who empirically received atypical coverage versus those who did not. We searched PubMed and EMBASE for randomized controlled trials (RCTs), comparing the clinical failure rate of CAP associated with individual atypical bacteria between adults who received empiric atypical coverage versus those who did not. Risk differences (RDs) with 95% confidence intervals (CIs) were calculated using random-effects models. Eight double-blind RCTs (65 patients with Legionella spp., 176 patients with M. pneumoniae, and 78 patients with C. pneumoniae) were included in the meta-analysis. The rate of clinical failure was significantly lower with empiric atypical coverage in CAP associated with Legionella spp. (RD, −42.6%; 95% CI, −69.8% to −15.4%; p-value = 0.002; I2 = 0%) and Mycoplasma pneumoniae (RD, −9.5%; 95% CI, −18.9% to −0.1%; p-value = 0.048; I2 = 0%), but not with Chlamydia pneumoniae (RD, 7.1%; 95% CI, −9.0% to 23.1%; p-value = 0.390; I2 = 0%). This meta-analysis of RCTs found that empiric atypical coverage decreased the clinical failure rate of CAP associated with Legionella spp. and M. pneumoniae, but not with C. pneumoniae.

Highlights

Community-acquired pneumonia (CAP) is one of the most common infections worldwide and is associated with significant morbidity and mortality [1,2,3]
randomized controlled trials (RCTs) reporting clinical efficacy of empiric atypical coverage versus no coverage (i.e., β-lactams) in adults with CAP caused by individual atypical bacteria (Legionella spp., M. pneumoniae, and C. pneumoniae) were included
The diagnosis of atypical bacteria was based on serology

Summary

Introduction

Community-acquired pneumonia (CAP) is one of the most common infections worldwide and is associated with significant morbidity and mortality [1,2,3]. The international incidence of atypical bacteria in patients with CAP is estimated to be 22% and varies according to the geographical region. The incidence of atypical bacteria in the US is approximately 4%, whereas in China, the incidence is approximately 40%, exceeding that of S. pneumoniae [4,5]. The true incidence is likely underestimated since it is not a standard of care in many countries to microbiologically identify these pathogens in respiratory cultures especially in the outpatient setting. Considering the undistinguished clinical features between atypical vs typical pathogens and the lack of an accurate and rapid diagnostic tool for pathogen identification, starting patients with CAP empirically on an antibiotic with atypical coverage might be warranted

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