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An interesting report by Lieberman and associates concluded that in two thirds of the patients infected with pneumonia caused by multiple agents, the severity of illness was not different from those infected by a single pathogen identified as M pneumoniae.
The academic opinion on whether patients infected with a single pathogen need to be treated differently, greatly varies. It is advisable that treatment decisions should be made empirically because it may be possible that no reliable clues are obtained at the time of diagnosis.
A recent meta-analysis clearly questions the validity of the usefulness of the time-honored Gram’s stain. However, as implied by the recent community acquired pneumonia guidelines stipulated by the infectious Disease Society of America, this view is not shared by some investigators. They suggest that Gram’s stain is not really useful and should not be relied upon to decide whether or not to limit broad spectrum therapy. It is advisable that until rapid diagnostic tests using molecular techniques become available, community acquired pneumonia should be treated empirically, based on clinical and radiographic observations.
In such a situation, the severity of the illness would determine its treatment. Young patients with no serious complications and without any real need to be hospitalized could remain outpatients and be treated with the newer macrolide or with doxycycline.
but if the patient is hospitalized due to the severity of illness and the presence of other serious complications, it has to be determined which infection requires to be treated first. In most cases, infections due to S pneumoniae need to be treated first. Also, appropriate therapy for L pneumophila would also be needed to minimize the risk of infection caused by mycoplasma and Chlamydia organisms.
The method of treatment depends on the presence of beta-lactam-resistant S pneumoniae is present in the individual community. As the incidence of such organisms is on the rise, the traditionally approved combination of a beta-lactam and a macrolide is surely going to be replaced by the use of fluoroquinolones. According to present trends the latter therapy is preferred for hospitalized patients.
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