RSS Feeds
Therapy for Legionnaires Disease
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
IN RESPONSE:
Dr. Johnson raises the important issue of empirical therapy for community-acquired pneumonia. The decision of whether to include treatment of Legionnaires disease in such therapy must be based on the chances of the patient having the disease and on the potential for harm if the disease is untreated. He rightly points out that there is great potential for the emergence of fluoroquinolone antimicrobial resistance if every patient with pneumonia receives that therapy. Empirical administration of a narrow-spectrum β-lactam antimicrobial agent alone may not be adequate therapy for several community-acquired infectious agents, including Mycoplasma pneumoniae, Chlamydia pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis, as well as Legionella species. Immunocompromised or previously hospitalized patients have the additional possibility of having infection caused by other, often multiresistant, pathogens.
This decision-making process has recently been made much more difficult by the emergence of pneumococci resistant to macrolides and cotrimoxazole. Different institutions and professional societies recommend different approaches to empirical therapy for pneumonia, but almost all include different therapies based on risk factors for pneumonia caused by resistant pathogens and different therapies for severely ill or immunocompromised patients (1-3). My view is that all immunocompromised patients and all patients hospitalized for pneumonia should be treated with a broader spectrum of antimicrobial agents than is used for relatively stable outpatients with pneumonia. However, that does not mean that all patients hospitalized for pneumonia should receive a fluoroquinolone antimicrobial agent for empirical therapy.
The current recommendations of our institutional antibiotic use committee for the empirical treatment of patients hospitalized with pneumonia are that patients younger than 60 years of age without comorbid conditions receive high-dosage intravenous penicillin and azithromycin therapy and that immunocompromised patients and those with comorbid conditions receive levofloxacin therapy (4). We are uncomfortable with the use of macrolide therapy alone because of the approximately 25% rate of pneumococcal resistance to these drugs in our community, and we have severely limited the empirical or specific use of third-generation antimicrobial agents because of the emergence of multiresistant gram-negative bacteria in our hospitals. Thus, all patients receiving our recommended empirical therapy for pneumonia are treated for Legionnaires disease, more often because of therapy directed at other pathogens than because of suspicion of this disease, which is rare in our community.
Paul H. Edelstein, MD
University of Pennsylvania Medical Center; Philadelphia, PA 19101-4283
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright ©2004 by the American College of Physicians
