さまよう薬剤師のブログ

学位を持っても、センスのない、感染制御専門薬剤師のブログ.  I have Ph.D. but less sense ID pharmacist.

Clinical failure with and without empiric atypical bacteria coverage in hospitalized adults with community-acquired pneumonia: a systematic review and meta-analysis.

2017年 6月 BMC Infect Dis に発表された、CAPに対するエンピリック非定型カバーの有無におけるClinical failure のsystematic review と meta-analysis。

 

 

 

BACKGROUND

Both typical and atypical bacteria can cause community-acquired pneumonia (CAP); however, the need for empiric atypical coverage remains controversial. Our objective was to evaluate the impact of antibiotic regimens with atypical coverage (a fluoroquinolone or combination of a macrolide/doxycycline with a β-lactam) to a regimen without atypical antibiotic coverage (β-lactam monotherapy) on rates of clinical failure (primary endpoint), mortality, bacteriologic failure, and adverse events, (secondary endpoints).

 

METHODS 

We searched the PubMed, EMBASE and Cochrane Library databases for relevant RCTs of hospitalized CAP adults. We estimated risk ratios (RRs) with 95% confidence intervals (CIs) using a fixed-effect model, but used a random-effects model if significant heterogeneity (I 2 ) was observed.

 

RESULTS 

Five RCTs with a total of 2011 patients were retained.

A statistically significant lower clinical failure rate was observed with empiric atypical coverage (RR, 0.851 [95% CI, 0.732-0.99; P = 0.037]; I 2  = 0%).

The secondary outcomes did not differ between the two study groups: mortality (RR = 0.549 [95% CI, 0.259-1.165, P = 0.118], I 2  = 61.434%) bacteriologic failure (RR = 0.816 [95% CI, 0.523-1.272, P = 0.369], I 2  = 0%), diarrhea (RR = 0.746 [95% CI, 0.311-1.790, P = 0.512], I 2  = 65.048%), and adverse events requiring antibiotic discontinuation (RR = 0.83 [95% CI, 0.542-1.270, P = 0.39], I 2  = 0%).

 

CONCLUSIONS

Empiric atypical coverage was associated with a significant reduction in clinical failure in hospitalized adults with CAP.

Reduction in mortality, bacterial failure, diarrhea, and discontinuation due to adverse effects were not significantly different between groups, but all estimates favored atypical coverage.

Our findings provide support for the current guidelines recommendations to include empiric atypical coverage.

 

 

Fig

 

f:id:akinohanayuki:20170711060310g:plain

 

f:id:akinohanayuki:20170711060320g:plain

 

f:id:akinohanayuki:20170711060333g:plain

 

査読過程

 

https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-017-2495-5/open-peer-review

 

感想

 

著者は下記のように強みを述べています。

The principal finding of our meta-analysis is that including empiric atypical coverage reduced the rates of clinical failure by approximately 15%. 

 

私は重症度を踏まえてどうなのか?と思いました。

非定型カバーはICU入院を考慮する場合などでいいのでは。

死亡率に差がなかったですしね。