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Thorax. Aug 2005; 60(8): 672–678.
PMCID: PMC1747487

Comparison between pathogen directed antibiotic treatment and empirical broad spectrum antibiotic treatment in patients with community acquired pneumonia: a prospective randomised study


Background: There is much controversy about the ideal approach to the management of community acquired pneumonia (CAP). Recommendations differ from a pathogen directed approach to an empirical strategy with broad spectrum antibiotics.

Methods: In a prospective randomised open study performed between 1998 and 2000, a pathogen directed treatment (PDT) approach was compared with an empirical broad spectrum antibiotic treatment (EAT) strategy according to the ATS guidelines of 1993 in 262 hospitalised patients with CAP. Clinical efficacy was primarily determined by the length of hospital stay (LOS). Secondary outcome parameters for clinical efficacy were assessment of therapeutic failure on antibiotics, 30 day mortality, duration of antibiotic treatment, resolution of fever, side effects, and quality of life.

Results: Three hundred and three patients were enrolled in the study; 41 were excluded, leaving 262 with results available for analysis. No significant differences were found between the two treatment groups in LOS, 30 day mortality, clinical failure, or resolution of fever. Side effects, although they did not have a significant influence on the outcome parameters, occurred more frequently in patients in the EAT group than in those in the PDT group (60% v 17%, 95% CI –0.5 to –0.3; p<0.001).

Conclusions: An EAT strategy with broad spectrum antibiotics for the management of hospitalised patients with CAP has comparable clinical efficacy to a PDT approach.

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Selected References

These references are in PubMed. This may not be the complete list of references from this article.
  • Fine MJ, Smith MA, Carson CA, Mutha SS, Sankey SS, Weissfeld LA, Kapoor WN. Prognosis and outcomes of patients with community-acquired pneumonia. A meta-analysis. JAMA. 1996 Jan 10;275(2):134–141. [PubMed]
  • Niederman MS, Bass JB, Jr, Campbell GD, Fein AM, Grossman RF, Mandell LA, Marrie TJ, Sarosi GA, Torres A, Yu VL. Guidelines for the initial management of adults with community-acquired pneumonia: diagnosis, assessment of severity, and initial antimicrobial therapy. American Thoracic Society. Medical Section of the American Lung Association. Am Rev Respir Dis. 1993 Nov;148(5):1418–1426. [PubMed]
  • Niederman MS, Mandell LA, Anzueto A, Bass JB, Broughton WA, Campbell GD, Dean N, File T, Fine MJ, Gross PA, et al. Guidelines for the management of adults with community-acquired pneumonia. Diagnosis, assessment of severity, antimicrobial therapy, and prevention. Am J Respir Crit Care Med. 2001 Jun;163(7):1730–1754. [PubMed]
  • Bartlett JG, Dowell SF, Mandell LA, File Jr TM, Musher DM, Fine MJ. Practice guidelines for the management of community-acquired pneumonia in adults. Infectious Diseases Society of America. Clin Infect Dis. 2000 Aug;31(2):347–382. [PubMed]
  • Wise R, Hart T, Cars O, Streulens M, Helmuth R, Huovinen P, Sprenger M. Antimicrobial resistance. Is a major threat to public health. BMJ. 1998 Sep 5;317(7159):609–610. [PMC free article] [PubMed]
  • Gould IM. A review of the role of antibiotic policies in the control of antibiotic resistance. J Antimicrob Chemother. 1999 Apr;43(4):459–465. [PubMed]
  • San Pedro GS, Campbell GD., Jr Limitations of diagnostic testing in the initial management of patients with community-acquired pneumonia. Semin Respir Infect. 1997 Dec;12(4):300–307. [PubMed]
  • Sanyal S, Smith PR, Saha AC, Gupta S, Berkowitz L, Homel P. Initial microbiologic studies did not affect outcome in adults hospitalized with community-acquired pneumonia. Am J Respir Crit Care Med. 1999 Jul;160(1):346–348. [PubMed]
  • Fine MJ, Auble TE, Yealy DM, Hanusa BH, Weissfeld LA, Singer DE, Coley CM, Marrie TJ, Kapoor WN. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med. 1997 Jan 23;336(4):243–250. [PubMed]
  • Ware JE, Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care. 1992 Jun;30(6):473–483. [PubMed]
  • Metlay JP, Fine MJ, Schulz R, Marrie TJ, Coley CM, Kapoor WN, Singer DE. Measuring symptomatic and functional recovery in patients with community-acquired pneumonia. J Gen Intern Med. 1997 Jul;12(7):423–430. [PMC free article] [PubMed]
  • Ramirez JA, Vargas S, Ritter GW, Brier ME, Wright A, Smith S, Newman D, Burke J, Mushtaq M, Huang A. Early switch from intravenous to oral antibiotics and early hospital discharge: a prospective observational study of 200 consecutive patients with community-acquired pneumonia. Arch Intern Med. 1999 Nov 8;159(20):2449–2454. [PubMed]
  • Rosón B, Carratalà J, Dorca J, Casanova A, Manresa F, Gudiol F. Etiology, reasons for hospitalization, risk classes, and outcomes of community-acquired pneumonia in patients hospitalized on the basis of conventional admission criteria. Clin Infect Dis. 2001 Jul 15;33(2):158–165. [PubMed]
  • Menéndez R, Ferrando D, Vallés JM, Martínez E, Perpiñ M. Initial risk class and length of hospital stay in community-acquired pneumonia. Eur Respir J. 2001 Jul;18(1):151–156. [PubMed]
  • Eron LJ, Passos S. Early discharge of infected patients through appropriate antibiotic use. Arch Intern Med. 2001 Jan 8;161(1):61–65. [PubMed]
  • Fine MJ, Medsger AR, Stone RA, Marrie TJ, Coley CM, Singer DE, Akkad H, Hough LJ, Lang W, Ricci EM, et al. The hospital discharge decision for patients with community-acquired pneumonia. Results from the Pneumonia Patient Outcomes Research Team cohort study. Arch Intern Med. 1997 Jan 13;157(1):47–56. [PubMed]
  • Boyter AC, Stephen J, Fegan PG, Nathwani D. Why do patients with infection remain in hospital once changed to oral antibiotics? J Antimicrob Chemother. 1997 Feb;39(2):286–288. [PubMed]
  • Farber BF, Cooper DJ. Observing patients after antibiotics are discontinued. N Engl J Med. 1995 Oct 19;333(16):1083–1084. [PubMed]
  • Dunn AS, Peterson KL, Schechter CB, Rabito P, Gotlin AD, Smith LG. The utility of an in-hospital observation period after discontinuing intravenous antibiotics. Am J Med. 1999 Jan;106(1):6–10. [PubMed]
  • Gleason PP, Meehan TP, Fine JM, Galusha DH, Fine MJ. Associations between initial antimicrobial therapy and medical outcomes for hospitalized elderly patients with pneumonia. Arch Intern Med. 1999 Nov 22;159(21):2562–2572. [PubMed]
  • Kalin M, Ortqvist A, Almela M, Aufwerber E, Dwyer R, Henriques B, Jorup C, Julander I, Marrie TJ, Mufson MA, et al. Prospective study of prognostic factors in community-acquired bacteremic pneumococcal disease in 5 countries. J Infect Dis. 2000 Sep;182(3):840–847. [PubMed]
  • Hook EW, 3rd, Horton CA, Schaberg DR. Failure of intensive care unit support to influence mortality from pneumococcal bacteremia. JAMA. 1983 Feb 25;249(8):1055–1057. [PubMed]
  • Knaus WA. Changing the cause of death. JAMA. 1983 Feb 25;249(8):1059–1060. [PubMed]
  • Lieberman D, Schlaeffer F, Boldur I, Lieberman D, Horowitz S, Friedman MG, Leiononen M, Horovitz O, Manor E, Porath A. Multiple pathogens in adult patients admitted with community-acquired pneumonia: a one year prospective study of 346 consecutive patients. Thorax. 1996 Feb;51(2):179–184. [PMC free article] [PubMed]
  • Lim WS, Macfarlane JT, Boswell TC, Harrison TG, Rose D, Leinonen M, Saikku P. Study of community acquired pneumonia aetiology (SCAPA) in adults admitted to hospital: implications for management guidelines. Thorax. 2001 Apr;56(4):296–301. [PMC free article] [PubMed]
  • Fang GD, Fine M, Orloff J, Arisumi D, Yu VL, Kapoor W, Grayston JT, Wang SP, Kohler R, Muder RR, et al. New and emerging etiologies for community-acquired pneumonia with implications for therapy. A prospective multicenter study of 359 cases. Medicine (Baltimore) 1990 Sep;69(5):307–316. [PubMed]
  • Mundy LM, Auwaerter PG, Oldach D, Warner ML, Burton A, Vance E, Gaydos CA, Joseph JM, Gopalan R, Moore RD, et al. Community-acquired pneumonia: impact of immune status. Am J Respir Crit Care Med. 1995 Oct;152(4 Pt 1):1309–1315. [PubMed]
  • File TM, Jr, Segreti J, Dunbar L, Player R, Kohler R, Williams RR, Kojak C, Rubin A. A multicenter, randomized study comparing the efficacy and safety of intravenous and/or oral levofloxacin versus ceftriaxone and/or cefuroxime axetil in treatment of adults with community-acquired pneumonia. Antimicrob Agents Chemother. 1997 Sep;41(9):1965–1972. [PMC free article] [PubMed]
  • Rosón B, Carratalà J, Verdaguer R, Dorca J, Manresa F, Gudiol F. Prospective study of the usefulness of sputum Gram stain in the initial approach to community-acquired pneumonia requiring hospitalization. Clin Infect Dis. 2000 Oct;31(4):869–874. [PubMed]
  • Mundy LM, Oldach D, Auwaerter PG, Gaydos CA, Moore RD, Bartlett JG, Quinn TC. Implications for macrolide treatment in community-acquired pneumonia. Hopkins CAP Team. Chest. 1998 May;113(5):1201–1206. [PubMed]
  • Stout JE, Yu VL. Legionellosis. N Engl J Med. 1997 Sep 4;337(10):682–687. [PubMed]
  • Farr BM, Kaiser DL, Harrison BD, Connolly CK. Prediction of microbial aetiology at admission to hospital for pneumonia from the presenting clinical features. British Thoracic Society Pneumonia Research Subcommittee. Thorax. 1989 Dec;44(12):1031–1035. [PMC free article] [PubMed]
  • van Kasteren ME, Wijnands WJ, Stobberingh EE, Janknegt R, van der Meer JW. Optimaliseren van het antibioticabeleid in Nederland. II. SWAB-richtlijnen voor antimicrobiële therapie bij thuis opgelopen pneumonie en bij nosocomiale pneumonie. Ned Tijdschr Geneeskd. 1998 Apr 25;142(17):952–956. [PubMed]
  • Gordon Kelley A, Biedenbach Douglas J, Jones Ronald N. Comparison of Streptococcus pneumoniae and Haemophilus influenzae susceptibilities from community-acquired respiratory tract infections and hospitalized patients with pneumonia: five-year results for the SENTRY Antimicrobial Surveillance Program. Diagn Microbiol Infect Dis. 2003 Aug;46(4):285–289. [PubMed]

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