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Title of Journal: Intensive Care Med

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Abbravation: Intensive Care Medicine

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Springer-Verlag

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DOI

10.1007/s11018-005-0205-y

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1432-1238

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Macrolide combination antibiotic therapy should be

Authors: HsinI Shih HsiangChin Hsu ChihHsien Chi WenChien Ko
Publish Date: 2010/07/15
Volume: 36, Issue: 10, Pages: 1788-1788
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Abstract

In response to the article by MartinLoeches et al 1 regarding improved survival in intubated patients with communityacquired pneumonia treated with combination antibiotic therapy with macrolides we would like to address several points regarding macrolide resistance and study populationIn the recent decade susceptibility of pneumococcus to macrolides in Asia has been very low Erythromycin susceptibility is 20 in Taiwan and Korea and about 25 in Hong Kong and China 2 Macrolideresistant strains ermB and mefA are widely circulating in Asia Low susceptibility of pneumococci to macrolides is difficult to deny According to a study in Taiwan macrolide susceptibility of pneumococci remains low even though macrolide usage has been decreasing for many years The rate of erythromycin resistance in streptococcal pneumonia showed an increasing trend from 802 in 1999 to 92 in 2003 3 4 The 2007 ATS/IDSA guidelines for communityacquired pneumonia CAP were based on epidemiology studies in the USA In the USA and Europe appropriate therapies in which a macrolide would be combined with a betalactam showed that macrolides may be effective in treating bacteremic pneumococcal pneumonia CAP severe sepsis and septic shock due to CAP 1 5 However synergic effects of macrolides and betalactams in treating invasive pneumococcal pneumonia in Asia may not be as good as in the USA and Europe Macrolides may be used only to empirically cover atypical pathogens such as Legionella or MycoplasmaMoreover in this article MartinLoeches et al did not indicate such detailed characteristics as underlying diseases pathogens disease severity or number of days of intensive care unit ICU stay for the empirical antimicrobial therapy group that was treated with a macrolide or for the empirical antimicrobial therapy group treated with fluoroquinolones The authors only indicated ICU mortality and that overall mortality in the macrolide group was lower than in the fluoroquinolones group Furthermore according to the 2007 ATS/IDSA guidelines for CAP subjects who were suggested to be treated by a fluoroquinolone and a betalactam combination were those with possible Pseudomonas infection In this study compared with the macrolide and betalactam combination group cases receiving fluoroquinolone and betalactam combination had lower proportions receiving thirdgeneration cephalosporins and higher proportions receiving fourthgeneration cephalosporins carbapenem and piperacillin/tazobactam Therefore cases receiving fluoroquinolone and betalactam combinations may have more complicated conditions than those receiving macrolide and betalactam combinations Since cases receiving a fluoroquinolone tended to have more complicated predisposing factors we could not expect that they would have better short and longterm prognosis

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