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• W2037473453 abstract "We read with interest the recent study by Cillóniz et al1Cillóniz C Polverino E Ewig S et al.Impact of age and comorbidity on etiology and outcome in community-acquired pneumonia.Chest. 2013; 144: 999-1007Abstract Full Text Full Text PDF PubMed Scopus (123) Google Scholar in CHEST (September 2013), in which several associations between the cause and outcome of community-acquired pneumonia (CAP) were reported in patients > 65 years of age, studied over a period of 12 years. The authors mention that the nonhomogeneous assessment of microbial cause is a potential limitation. In our opinion, this is an understatement of the bias that may have resulted from this approach, and this limitation precludes the conclusion that was reached. The most important finding of the study was that the presence of comorbidities was associated more with potential multidrug-resistant (MDR) pathogens as a cause of CAP than was age. Thus, the authors concluded that “comorbidities rather than age should be considered in the selection of antibiotic treatment.” However, the outcome (in this case, a microbial cause) was not assessed uniformly in all included patients, which is a well-known cause of bias in predictive research.2Moons KG Royston P Vergouwe Y Grobbee DE Altman DG Prognosis and prognostic research: what, why, and how?.BMJ. 2009; 338: b375Crossref PubMed Scopus (768) Google Scholar Apparently, microbial testing was left to the discretion of the treating physician. This is at least suggested by the pattern of microbial testing: serologic tests in 1,537 patients (44%), sputum cultures in 1,913 patients (54%), and blood cultures in 2,753 patients (78%).3Cillóniz C Ewig S Polverino E et al.Microbial aetiology of community-acquired pneumonia and its relation to severity.Thorax. 2011; 66: 340-346Crossref PubMed Scopus (208) Google Scholar By ignoring the fact that microbial tests could be different across patients, the authors implicitly assumed that the tests were missing at random. However, in clinical practice, the choice for microbial testing is often influenced by patient and disease characteristics. Therefore, more extensive diagnostic testing in patients with comorbidities may well explain the higher prevalence of potential MDR pathogens in this patient group. Demonstration of comparable diagnostic procedures in patients with and without comorbidities would reduce the likelihood of bias, although even that would not rule out bias completely. It is hardly possible to adjust for this analytically, even when information on why certain microbial tests were (or were not) obtained was available. Because of global aging and the corresponding increase in the number of comorbidities, which will also occur in patients with CAP, a recommendation to include MDR antibiotic coverage based on comorbidities inevitably increases antibiotic use. In an era of increasing antimicrobial resistance and a high prevalence of nosocomial Clostridium difficile infection, such recommendations should be based on unbiased results. Because the cause of CAP cannot be reliably determined by clinical data, empirical antibiotic therapy should be guided by local epidemiologic data, the site of admission, and prior microbial culture results, rather than by the presence of comorbidities. Predicting Community-Acquired Pneumonia Etiology: ResponseCHESTVol. 144Issue 6PreviewWe appreciate the interest of Dr Postma and colleagues in our recently published article in CHEST.1 In the Discussion section of our article, we already acknowledged that a potential limitation of the study is not having 100% microbial etiologies. This study comes from our database, with information collected prospectively over 12 years from patients with community-acquired pneumonia (CAP) who had a well-defined diagnostic and treatment protocol from the very beginning; we disagree with the suggestion that “apparently, microbial testing was left to the discretion of the treating physician.” Full-Text PDF" @default.
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• W2037473453 date "2013-12-01" @default.
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• W2037473453 title "Predicting Community-Acquired Pneumonia Etiology" @default.
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• W2037473453 doi "https://doi.org/10.1378/chest.13-1756" @default.
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