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BMJ. 2007 December 1; 335(7630): 1109.
PMCID: PMC2099541
Community Acquired Pneumonia

Antibiotic coverage is atypical: evidence from randomised trials

Leonard Leibovici, head, Department of Medicine E, Eyal Robenshtock, senior physician, Department of Medicine E, and Mical Paul, consultant, Infectious Diseases Unit

Bjerre quotes an observational study to support the addition of antibiotics that cover atypical pathogens to the treatment of patients with community acquired pneumonia.1 The results of randomised controlled trials dealing with this question were amassed in two recent systematic reviews and meta-analyses (one published in the BMJ), which were not quoted in the editorial.2 3 Our systematic review included 24 trials, which randomised 5015 patients.3 Mortality was no different in the arm that provided atypical coverage and the arm that did not (relative risk 1.13, 95% confidence interval 0.82 to 1.54). Regimens that covered atypical pathogens showed a trend towards clinical success and a significant advantage to bacteriological eradication. Both disappeared when evaluating methodologically high quality studies alone. Nearly all studies compared a β lactam with a single quinolone or macrolide, and we found no study that compared the addition of a macrolide to a β lactam drug.

We believe that observational studies cannot answer this question, as patients given drugs with atypical coverage in clinical practice are different from patients given drugs without atypical coverage, and these differences are probably not captured or accounted for in observational studies.4

Research evidence does not support the addition of drugs with atypical coverage to the empirical treatment of patients with community acquired pneumonia.2 3 A randomised clinical trial comparing treatment with a β lactam to a combination of a β lactam and a macrolide is needed.


Competing interests: None declared.


Bjerre LM. Management of community acquired pneumonia. BMJ 2007;335:1004-5. (17 November.) [PMC free article] [PubMed]
Mills GD, Oehley MR, Arrol B. Effectiveness of β lactam antibiotics compared with antibiotics active against atypical pathogens in non-severe community acquired pneumonia: meta-analysis. BMJ 2005;330:456. [PMC free article] [PubMed]
Shefet D, Robenshtok E, Paul M, Leibovici L. Empirical atypical coverage for inpatients with community-acquired pneumonia: systematic review of randomized controlled trials. Arch Intern Med 2005;165:1992-2000. [PubMed]
Paul M, Nielsen AD, Gafter-Gvili A, Tacconelli E, Andreassen S, Almanasreh N, et al. The need for macrolides in hospitalised community-acquired pneumonia: propensity analysis. Eur Respir J 2007;30:525-31. [PubMed]

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