在社區型肺炎的住院成人中，涵蓋非典型病原菌經驗性抗生素
Abstract
Background
Community‐acquired pneumonia (CAP) is caused by various pathogens, traditionally divided into 'typical' and 'atypical'. Initial antibiotic treatment of CAP is usually empirical, customarily covering both typical and atypical pathogens. To date, no sufficient evidence exists to support this broad coverage, while limiting coverage is bound to reduce toxicity, resistance and expense.
Objectives
The main objective was to estimate the mortality and proportion with treatment failure using regimens containing atypical antibiotic coverage compared to those that had typical coverage only. Secondary objectives included the assessment of adverse events.
Search methods
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) Issue 3, 2012 which includes the Acute Respiratory Infection Group's Specialized Register, MEDLINE (January 1966 to April week 1, 2012) and EMBASE (January 1980 to April 2012).
Selection criteria
Randomized controlled trials (RCTs) of adult patients hospitalized due to CAP, comparing antibiotic regimens with atypical coverage (quinolones, macrolides, tetracyclines, chloramphenicol, streptogramins or ketolides) to a regimen without atypical antibiotic coverage.
Data collection and analysis
Two review authors independently assessed the risk of bias and extracted data from included trials. We estimated risk ratios (RRs) with 95% confidence intervals (CIs). We assessed heterogeneity using a Chi2 test.
Main results
We included 28 trials, encompassing 5939 randomized patients. The atypical antibiotic was administered as monotherapy in all but three studies. Only one study assessed a beta‐lactam combined with a macrolide compared to the same beta‐lactam. There was no difference in mortality between the atypical arm and the non‐atypical arm (RR 1.14; 95% CI 0.84 to 1.55), RR < 1 favors the atypical arm. The atypical arm showed an insignificant trend toward clinical success and a significant advantage to bacteriological eradication, which disappeared when evaluating methodologically high quality studies alone. Clinical success for the atypical arm was significantly higher for Legionella pneumophilae (L. pneumophilae) and non‐significantly lower for pneumococcal pneumonia. There was no significant difference between the groups in the frequency of (total) adverse events, or those requiring discontinuation of treatment. However, gastrointestinal events were less common in the atypical arm (RR 0.70; 95% CI 0.53 to 0.92). Although the trials assessed different antibiotics, no significant heterogeneity was detected in the analyses.
Authors' conclusions
No benefit of survival or clinical efficacy was shown with empirical atypical coverage in hospitalized patients with CAP. This conclusion relates mostly to the comparison of quinolone monotherapy to beta‐lactams. Further trials, comparing beta‐lactam monotherapy to the same combined with a macrolide, should be performed.
PICO
Plain language summary
為了治療因社區型肺炎住院的成人，使用具有抗非典型病原體(atypical pathogens)活性之抗生素
肺炎(pneumonia)為嚴重的肺部感染症狀，臨床上經常使用抗生素來治療。造成社區型肺炎 (CAP) 的細菌傳統上被分為典型、非典型兩種，各自需要不同的抗生素治療(社區型肺炎：在醫療機機構外感染的肺炎)。非典型肺炎之致病菌包含嗜肺性退伍軍人桿菌症 (Legionella pneumophila)(L. pneumophila)、黴漿菌 (Mycoplasma pneumoniae)(M.pneumoniae) 及 披衣菌 (Chlamydia pneumoniae)(C. pneumoniae)。典型社區型肺炎主要感染源為 肺炎鏈球菌 （Streptococcus pneumoniae ）.社區型肺炎有許多潛在致病菌，因此不太可能在治療前即確定是哪個菌株導致的，故治療常以囊括典型、非典型菌株的經驗性抗生素給藥 雖然囊括典型菌株的抗生素治療是必須的，但是否需涵蓋非典型菌株則尚未有定論。在本回顧文獻的前一版中，我們發現經驗性使用涵蓋非典型菌株之抗生素沒有好處。但因現有的肺炎指引與臨床文獻結果相互矛盾，故我們再次進行了本回顧文獻的更新。
這項Cochrane綜述著眼於比較非典型抗生素治療方案與非典型治療方案（僅限於住院的CAP成人）的試驗。我們收錄了28件試驗，其中總共含5,939位病人。在死亡率、臨床療效這兩個主要監測指標上，非典型菌株之經驗性抗生素使用並無優勢。兩組在總不良事件發生頻率或需要中斷治療的發生頻率無顯著差異。然而，胃腸道不良事件在非典型菌株組別中發生率較低。
本次回顧證據力有其限制，大多文獻比較了單一非典型抗生素與單一典型抗生素。另外有篇文獻比較了將非典型抗生素添加入典型抗生素之差異。 在全部27件實驗中，有17件為開放式試驗(open label)、其中有21件為藥廠贊助 (其中一件試驗由非典型抗生素的藥品製造商自己執行)。
