Thursday, April 16, 2015

Community Acquired Pneumunia


Share |NEJM reports a study of community acquired pneumonia comparing treatment with bata lactams, macrolide-beta lactams combination therapy or fluoroquinolone mono-therapy with mortality.

Why "community acquired pneumonia"? Hippocrates was more specific. By the very name we are excusing ourselves from the very art of clinical diagnosis that has taken centuries to develope. We have not replaced that art with PCR or fluorescent microscopy. The term community acquired pneumonia can only be an excuse for expedient treatment and disposition. I would wager that the stethoscope was applied over the shirt and the acknowlegment of community acquired pneumonia not made until the X-ray was positive. By then we might better call it late diagnosis of pneumonia of unknown etiology obscured by inappropriate antibiotic therapy.

Rene Lanec brought us the stethoscope, but we wear it around our neck, color coordinated as a fashion statement and we listen through clothing if at all. One should easily diagnose pneumonia before the X-ray is positive and with a bit of a history and a Gram stain narrow down the etiology and a culture before starting any antibiotic.

d-pneumo. Is the easiest to identify with a Gram stain and any strings of strep. clearly justify beta-lactams. Macrolides cover the hard to identify atypical pneumonia and the clumps of staph on the slide suggest a more resistant organism. Beta lactam macrolide in combination may still cover the possibility of atypical, but with the combination of a bacterialstatic with a bacterialsisal, the one may inhibit the effectiveness of the other. Then there is TB and pneumonocysticis - in more vulnerable patients. But what is community acquired pneumonia other than an excuse.

NEJM 2015,372: 1312-1323;  2 April. DOI 10.1056/NEJMoa1406330