【Cochrane简语概要】社区获得性肺炎患者最初使用非典型病原体抗生素 用药覆盖范围

肺炎是一种严重的肺部感染疾病，通常使用抗生素治疗。导致社区获得性肺炎（community-acquired pneumonia, CAP，在医疗机构外感染的肺炎）的细菌传统上分为"典型"和"非典型"，每种都规定使用不同的抗生素治疗。非典型细菌包括嗜肺军团菌（L. pneumophila）、肺炎支原体（M. pneumoniae）和肺炎肺炎衣原体（C. pneumoniae）。引起CAP的主要典型致病菌代表是肺炎链球菌（S. pneumoniae）。通常无法确定许多潜在因素中哪种是导致CAP的原因，因此抗生素治疗是经验性的，通常包括典型和非典型细菌。虽然覆盖典型病原体至关重要，但是覆盖非典型病原体的必要性尚未得到证实。在本综述的前一版本中，我们表明覆盖非典型病原体没有优势。鉴于目前治疗肺炎的指南与现有证据之间一直存在不一致性，我们对本系统综述进行了更新。

本Cochrane综述比较了抗生素标准方案在覆盖典型与非典型致病菌中的应用，仅限于住院的成年人CAP试验。我们共纳入28项试验，涉及5939名患者。对于测试的治疗方案，在测试的主要结局--死亡率和临床疗效中，对覆盖非典型细菌的治疗方案没有优势。两组在总不良事件或需要停止治疗的频率上没有显著差异。然而，胃肠道事件在覆盖非典型病原体中并不常见。

本综述存在一定局限性，因为只有一项研究将非典型抗生素的附加与典型抗生素的进行比较，这是临床实践中的主要问题；大多数人将一种非典型抗生素与一种典型抗生素进行比较。27项试验中有17项是公开标签，27项研究中有21项由制药公司赞助，其中只有1项是由非典型抗生素的制造商赞助的。

（图片来源于网络）

结论: 

在住院的CAP患者中，不典型覆盖的经验用药没有显示出任何生存或临床疗效的益处这一结论主要与喹诺酮类药物单药治疗与β-内酰胺类药物的比较有关。应进行进一步的试验，将β-内酰胺单药治疗与联合大环内酯治疗进行比较。

译者：李海燕，北京中医药大学志愿者；审校：刘雪寒、金信妍、鲁春丽；编辑排版：刘美迪，张晓雯，北京中医药大学循证医学中心

相关文章链接

【Cochrane Plain Language Summary】Initial antibiotic treatment for coverage of 'atypical' pathogens for community‐acquired pneumonia in hospitalized adults

Pneumonia is a serious lung infection and is usually treated with antibiotics. Bacteria which cause community‐acquiredpneumonia (CAP, pneumonia contracted outside healthcare settings) are traditionally divided into 'typical' and 'atypical', each dictating a different antibiotic treatment. Atypical bacteria include, Legionella pneumophila (L. pneumophila), Mycoplasma pneumoniae (M. pneumoniae) and Chlamydia pneumoniae (C. pneumoniae). The main 'typical' agent causing CAP is Streptococcus pneumoniae (S. pneumoniae). It is usually not possible to determine which of the many potential agents is the cause of CAP, so that antibiotic treatment is empirical, customarily covering both typical and atypical bacteria. While typical coverage is essential, the necessity of the atypical coverage has not been proven. In the previous version of this review we showed that there was no advantage to the atypical arm. Given the persisting inconsistency between current guidelines for treatment ofpneumonia and the available evidence, we undertook to update this systematic review. 

This Cochrane review looked at trials comparing antibiotic regimens with atypical coverage to those without, limited to hospitalized adults with CAP. We included 28 trials, involving 5939 patients. For the regimens tested, no advantage was found forregimens covering atypical bacteria in the major outcomes tested ‐ mortality and clinical efficacy. 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. 

There are limitations to this review in that a single study compared the addition of the atypical antibiotic to a typical antibiotic, the major question in clinical practice; most compared a single atypical antibiotic to a single typical antibiotic. Seventeen of the 27 trials were open label, 21 of the 27 studies were sponsored by pharmaceutical companies of which all but one was conducted by the manufacturer of the atypical antibiotic.

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.

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