RESPONSE LETTER TO DR. BOBBA ET AL.

Abstract

To the Editor: We appreciate the opportunity to address the issues raised by Bobba et al. To dispel apparent misconceptions regarding how our patients were treated, initial examinations considered aspiration pneumonia, and all patients were evaluated daily for clinical response, safety, and potential for a switch from intravenous to oral administration. We are curious as to the implication that combination therapy was warranted and wonder what sort of extra coverage is advocated. Regarding aspiration pneumonia, antibiotic therapy would not have changed, because the study antibiotics cover aerobic and anaerobic oropharyngeal pathogens adequately.1, 2 We had already noted that, with the exception of outbreak situations of Legionella pneumophilia, atypical pathogens are infrequent causes of nursing home–acquired pneumonia (NHAP) and do not normally require empirical coverage.3 Regarding guidelines, the suggestion for treating nonambulatory residents of long-term care facilities (LTCFs) is mentioned only briefly in the recent consensus guidelines for community-acquired pneumonia.2 That statement directs the reader to the consensus guidelines for treatment of healthcare-associated pneumonia (HCAP).1 Careful examination of those guidelines reveals a strong bias toward hospitalized patients and the acknowledgment that the evidence-based studies of the relationship between risk factors and bacteriology were primarily of patients with ventilator-associated pneumonia, which were then extrapolated to patients with HCAP.1 The guideline committee considered patients admitted to the hospital from an LTCF to be at risk for multidrug-resistant pathogens and as such recommended initial empirical antibiotic therapy as a combination of three intravenous antibiotics (Table 4 in1). Appropriate candidates for such aggressive regimens would most certainly require hospitalization. In contrast, our patients did not require hospitalization at the time of study enrollment, and many were ambulatory. For these and other reasons, we chose to follow the guidelines specifically developed for NHAP, which do not recommend combination therapy.4 Of the seven evaluable patients who were hospitalized and the five who died (Table 1), none experienced documented microbiological failure of the study antibiotic. Finally, few residents had received systemic antibiotics in the preceding 90 days. Regardless, all patients had baseline blood cultures obtained and sputum cultures attempted; few had resistant pathogens isolated.3 In summary, we consider the treatment of the patients in our study to have been appropriate and consistent with the guidelines for treating NHAP.4 Conflict of Interest: Dr. Paladino has been (although is no longer) a grant recipient and received honoraria as member of the speaker's bureau and advisory boards for Élan Pharmaceuticals. In reviewing the submitted checklist of financial and personal conflict, with the exception of above, the editor in chief has determined that none of the authors in this paper has any personal or financial conflicts in regards to this paper. Author Contributions: Drs. Paladino and Eubanks participated fully in writing the response. Sponsor's Role: None.