{"id":1840,"date":"2015-08-06T13:09:07","date_gmt":"2015-08-06T17:09:07","guid":{"rendered":"http:\/\/allphasepharma.com\/dir\/?p=1840"},"modified":"2015-08-06T13:09:07","modified_gmt":"2015-08-06T17:09:07","slug":"the-etiology-of-cap-remains-elusive-a-call-to-change-antibiotic-prescribing-patterns","status":"publish","type":"post","link":"https:\/\/allphasepharma.com\/dir\/2015\/08\/06\/1840\/the-etiology-of-cap-remains-elusive-a-call-to-change-antibiotic-prescribing-patterns\/","title":{"rendered":"The Etiology of CAP Remains Elusive \u2013 A Call to Change Antibiotic Prescribing Patterns"},"content":{"rendered":"<p><a href=\"https:\/\/i0.wp.com\/allphasepharma.com\/dir\/wp-content\/uploads\/2015\/08\/CAP-slider-2.jpg?ssl=1\"><img data-recalc-dims=\"1\" loading=\"lazy\" decoding=\"async\" class=\"alignright size-full wp-image-1847\" src=\"https:\/\/i0.wp.com\/allphasepharma.com\/dir\/wp-content\/uploads\/2015\/08\/CAP-slider-2.jpg?resize=530%2C149&#038;ssl=1\" alt=\"CAP slider 2\" width=\"530\" height=\"149\" srcset=\"https:\/\/i0.wp.com\/allphasepharma.com\/dir\/wp-content\/uploads\/2015\/08\/CAP-slider-2.jpg?w=640&amp;ssl=1 640w, https:\/\/i0.wp.com\/allphasepharma.com\/dir\/wp-content\/uploads\/2015\/08\/CAP-slider-2.jpg?resize=300%2C84&amp;ssl=1 300w\" sizes=\"auto, (max-width: 530px) 100vw, 530px\" \/><\/a><\/p>\n<p>Once upon\u00a0a time &#8211; not so long ago &#8211;\u00a0we were taught the following:<\/p>\n<ul>\n<li>Streptococcus pneumoniae was the cause of 90% of CAP cases. That statement was later modified to mean S. pneumoniae was the underlying pathogen in 90% of bacterial\u00a0cases of CAP, i.e., those with positive cultures from sputum or blood;<\/li>\n<li>S. pneumoniae was the \u201ccaptain of the men of death\u201d and that pneumonia caused by the organism was associated with a high mortality.<\/li>\n<\/ul>\n<p>It\u00a0was the time when students, residents and fellows had to check a sputum Gram stain of every CAP patient to see whether an encapsulated diplococcus was present.\u00a0 Nobody quite understood why this had to be done at 3 o\u2019clock in the morning when the patient ended up on penicillin anyways but it was taught and defended as good practice. Occasionally you were rewarded with an unequivocal specimen giving away the diagnosis.<\/p>\n<p>Now we learn from\u00a0a large study of CAP patients requiring hospitalization that S. pneumoniae is a rare pathogen being confronted in US hospitals<a href=\"#_ftn1\" name=\"_ftnref1\">[1]<\/a>.\u00a0 Despite state-of-the-art diagnostics which included not only traditional Gram stain and cultures but also serology, urinary antigen testing and PCR for a long list of respiratory viruses, S. pneumoniae was positively identified in only 5% (sic!) of cases. \u00a0<div class=\"simplePullQuote right\"><p><strong><span style=\"color: #ff0000\">Only 115 of 2259 hospitalized patients (5%) had a bona fide pneumococcal infection<\/span><\/strong><br \/>\n<span style=\"color: #000000\">JAIN et al. \u00a0NEJM 373; 5: 415<\/span><\/p>\n<\/div><\/p>\n<p>This is a surprisingly low percentage for which the authors invoke the \u2018herd immunity\u2019 effect of successful childhood immunization with polyvalent vaccine.\u00a0 Prior antibiotic use, a figure not provided in the article, may have resulted in culture-negativity but should not have affected urinary antigen detection.<\/p>\n<p>Perhaps less surprisingly, a bacterial etiology could be proven in only 14% of cases of which only 11% were purely bacterial in nature. Despite exhaustive testing, no pathogen (viral, bacterial, fungal or chlamydial) could be identified in 62% of CAP patients.<\/p>\n<p>It seems that we need to revise our approach to CAP.\u00a0 We need to think inflammation, not infection; viral, not bacterial, in\u00a0the overwhelming majority of cases.<div class=\"simplePullQuote right\"><p><strong><span style=\"color: #000080\">Is there really a need to treat every CAP patient\u00a0with antibiotics when the overall mortality is as low as 2% even in hospitalized patients?<\/span><\/strong><\/p>\n<\/div> \u00a0Would watchful watching be a better approach than the current standard which is combination antibiotic therapy in accordance with 2007 ATS\/IDSA CAP treatment guidelines\u00a0<a href=\"#_ftnref2\" name=\"_ftn2\">[2]<\/a>\u00a0?\u00a0 While not mentioned in the publication, we can safely assume that in the cohort of 2259 patients every single one received systemic antibiotics for the duration of hospitalization.<\/p>\n<p>Are we giving antibiotics to CAP patients, because we don\u2019t trust negative cultures and feel they\u00a0can exclude a bacterial etiology? \u00a0No, it is more likely that US doctors practice \u2018defensive medicine knowing that the lawyers will have a heyday if they withhold \u2018life-saving\u2019 drugs, or\u00a0don\u2019t follow \u2018state-of-the-art\u2019 practices.<\/p>\n<p>Before we invoke \u2018antibiotic stewardship\u2019 and\u00a0talk about \u2018inappropriate use\u2019 of antibiotics, we need to acknowledge the \u2018elefant in the room\u2019: Even in 2015, our ability to diagnose the different etiologies of what presents as &#8216;pneumonitis&#8217; (i.e., new infiltrate on CXR plus fever and leukocytosis) is abysmally poor. \u00a0This is quite embarrassing to admit.<\/p>\n<p>Maybe it is time for a radical break with traditional approaches. \u00a0Instead of working on new guidelines, we need a fundamental understanding of the disease and improved diagnostics. \u00a0What we are doing therapeutically just does not make sense anymore.<\/p>\n<p>Recently, the need for macrolide therapy in CAP has been challenged in a widely quoted study<a href=\"#_ftn2\" name=\"_ftnref2\">[3]<\/a>.\u00a0 How about the approach proffered by FDA a few years ago to demand placebo-controlled trials in CAP (or CABP)?\u00a0 It did not get much traction at the time but a few\u00a0more studies confirming the Jain and Postma findings may trigger a sea change.<\/p>\n<p>Somehow one would believe that we should not wait for the FDA to tell us that \u201cthe science has changed\u201d.<\/p>\n<p><strong>References:<br \/>\n<\/strong><a href=\"#_ftnref1\" name=\"_ftn1\">[1]<\/a> S Jain. N Engl J Med 2015; 373: 415<br \/>\n<a href=\"#_ftnref2\" name=\"_ftn2\">[2]<\/a> Mandell L Clin Infect Dis. 2007;44: S27<br \/>\n<a href=\"#_ftnref2\" name=\"_ftn2\">[3]<\/a>\u00a0D Postma. N Engl J Med 2015; 372:1312<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Once upon\u00a0a time &#8211; not so long ago &#8211;\u00a0we were taught the following: Streptococcus pneumoniae was the cause of 90% of CAP cases. That statement was later modified to mean S. pneumoniae was the underlying pathogen in 90% of bacterial\u00a0cases of CAP, i.e., those with positive cultures from sputum or <a class=\"more-link\" href=\"https:\/\/allphasepharma.com\/dir\/2015\/08\/06\/1840\/the-etiology-of-cap-remains-elusive-a-call-to-change-antibiotic-prescribing-patterns\/\">Continue reading <span class=\"screen-reader-text\">  The Etiology of CAP Remains Elusive \u2013 A Call to Change Antibiotic Prescribing Patterns<\/span><span class=\"meta-nav\">&rarr;<\/span><\/a><\/p>\n","protected":false},"author":1,"featured_media":1847,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"jetpack_post_was_ever_published":false,"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_publicize_message":"","jetpack_publicize_feature_enabled":true,"jetpack_social_post_already_shared":true,"jetpack_social_options":{"image_generator_settings":{"template":"highway","default_image_id":0,"font":"","enabled":false},"version":2}},"categories":[227,3,18],"tags":[403,334,1257,442,1254,1253,639,1244,1247,1255,1243,5,1251,1252,162,1246,1256,1248,1249,1250,1245],"class_list":["post-1840","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-recent_literature","category-the_news","category-the_viewpoint","tag-antibiotic-blog","tag-antibiotic-stewardship","tag-atsidsa-guidelines","tag-cap","tag-cap-guidelines","tag-cap-mortality","tag-cdc","tag-community-acquired-pneumonia","tag-diagnosis-of-pneumonia","tag-diplococcus-pneumoniae","tag-epic-study","tag-fda","tag-hospitalization-for-cap","tag-inappropriate-antibiotic-use","tag-penicillin","tag-pneumococcal-pneumonia","tag-pneumococcal-vaccine","tag-pneumonitis","tag-role-of-antibiotics","tag-role-of-macrolides-in-cap","tag-s-pneumoniae-pneumonia"],"jetpack_publicize_connections":[],"jetpack_featured_media_url":"https:\/\/i0.wp.com\/allphasepharma.com\/dir\/wp-content\/uploads\/2015\/08\/CAP-slider-2.jpg?fit=640%2C180&ssl=1","jetpack_shortlink":"https:\/\/wp.me\/p4KWFr-tG","jetpack_sharing_enabled":true,"jetpack-related-posts":[{"id":1287,"url":"https:\/\/allphasepharma.com\/dir\/2015\/03\/05\/1287\/the-pneumococcus-prominent-microbiologists-contributions-and-cross-connections\/","url_meta":{"origin":1840,"position":0},"title":"The Pneumococcus, Prominent Microbiologists, Contributions and Cross-Connections","author":"Harald","date":"March 5, 2015","format":false,"excerpt":"\u2018He who knows syphilis knows medicine\u2019 goes the saying. In a similar way this adage could be applied to the Pneumococcus, aka Streptococcus pneumoniae, Diplococcus pneumoniae or Diplococcus lanceolatus by saying \u201cHe who knows S. pneumoniae knows microbiology\u201d. Many \u2018big names\u2019 studied the\u00a0organism. \u00a0Their work on the Pneumococcus led to\u2026","rel":"","context":"In &quot;Did you know...?&quot;","block_context":{"text":"Did you know...?","link":"https:\/\/allphasepharma.com\/dir\/category\/interesting_facts\/"},"img":{"alt_text":"PNEUMOCOCCUS copy","src":"https:\/\/i0.wp.com\/allphasepharma.com\/dir\/wp-content\/uploads\/2015\/03\/PNEUMOCOCCUS-copy.jpg?resize=350%2C200","width":350,"height":200},"classes":[]},{"id":1362,"url":"https:\/\/allphasepharma.com\/dir\/2015\/04\/08\/1362\/arties-law-avoid-bad-advice-and-dont-follow-mission-impossible-advice\/","url_meta":{"origin":1840,"position":1},"title":"Artie\u2019s Law: Avoid Bad Advice and Don\u2019t Follow \u2018Mission Impossible\u2019 Advice","author":"Harald","date":"April 8, 2015","format":false,"excerpt":"In this day and age, few truly broad spectrum antibiotics are in development, although this does not hold true for narrow-spectrums.\u00a0 Just think of all the MRSA drugs (quinolones, FabI inhibitors), the pseudomonas drugs (NCEs and monoclonals) or some narrow spectrum drugs that will need to be tested in MDR\u2026","rel":"","context":"In &quot;The Viewpoint&quot;","block_context":{"text":"The Viewpoint","link":"https:\/\/allphasepharma.com\/dir\/category\/the_viewpoint\/"},"img":{"alt_text":"","src":"","width":0,"height":0},"classes":[]},{"id":3100,"url":"https:\/\/allphasepharma.com\/dir\/2017\/01\/24\/3100\/kill-mocking-bug-cre-crab-variety\/","url_meta":{"origin":1840,"position":2},"title":"To Kill A Mocking Bug &#8211; of the CRKP or CRAB Variety","author":"Harald","date":"January 24, 2017","format":false,"excerpt":"Meropenem stands out as an antibiotic to be used first in ESBL and MDR infections, given its efficacy profile and safety record (see earlier blog). It also would seem to be appropriate to use relatively high doses or prolonged infusion times \u2013 or both - to improve T>MIC for the\u2026","rel":"","context":"In &quot;Recent Literature&quot;","block_context":{"text":"Recent Literature","link":"https:\/\/allphasepharma.com\/dir\/category\/recent_literature\/"},"img":{"alt_text":"","src":"https:\/\/i0.wp.com\/allphasepharma.com\/dir\/wp-content\/uploads\/2017\/01\/Mero-slider.jpg?resize=350%2C200","width":350,"height":200,"srcset":"https:\/\/i0.wp.com\/allphasepharma.com\/dir\/wp-content\/uploads\/2017\/01\/Mero-slider.jpg?resize=350%2C200 1x, https:\/\/i0.wp.com\/allphasepharma.com\/dir\/wp-content\/uploads\/2017\/01\/Mero-slider.jpg?resize=525%2C300 1.5x"},"classes":[]},{"id":671,"url":"https:\/\/allphasepharma.com\/dir\/2014\/08\/02\/671\/learning-from-set-backs-the-frustrating-search-for-a-staphylococcal-vaccine\/","url_meta":{"origin":1840,"position":3},"title":"Learning from Set-Backs:  The Frustrating Search for a Staphylococcal Vaccine","author":"Harald","date":"August 2, 2014","format":false,"excerpt":"Several reasons have been proposed as explanations why so many\u00a0S. aureus vaccines\u00a0have failed in clinical trials.\u00a0 Clearly, the organism has a battery of virulence factors which may require a multipronged approach and\u00a0neutralizing just a single mechanism with a specific mAb may not suffice. However, passive immunization with polyclonal antibodies did\u2026","rel":"","context":"In &quot;Recent Literature&quot;","block_context":{"text":"Recent Literature","link":"https:\/\/allphasepharma.com\/dir\/category\/recent_literature\/"},"img":{"alt_text":"IgG antibody","src":"http:\/\/allphasepharma.com\/dir\/wp-content\/uploads\/2014\/08\/antibody.jpe","width":350,"height":200},"classes":[]},{"id":4745,"url":"https:\/\/allphasepharma.com\/dir\/2025\/07\/18\/4745\/cabp-trial-enrollment-but-not-in-the-usa\/","url_meta":{"origin":1840,"position":4},"title":"CABP TRIAL ENROLLMENT \u2013 BUT NOT IN THE USA","author":"Harald","date":"July 18, 2025","format":false,"excerpt":"Today\u2019s topic is about the lackluster recruitment of US centers in recent CABP trials. We noticed that Eastern European (EE) centers, specifically from Ukraine, Bulgaria, and Serbia, contribute patients in large numbers, actually making these trials feasible.\u00a0 When sponsors and CROs needed to enroll CABP patients, they could not rely\u2026","rel":"","context":"In &quot;Did you know...?&quot;","block_context":{"text":"Did you know...?","link":"https:\/\/allphasepharma.com\/dir\/category\/interesting_facts\/"},"img":{"alt_text":"","src":"https:\/\/i0.wp.com\/allphasepharma.com\/dir\/wp-content\/uploads\/2025\/07\/image.png?resize=350%2C200&ssl=1","width":350,"height":200,"srcset":"https:\/\/i0.wp.com\/allphasepharma.com\/dir\/wp-content\/uploads\/2025\/07\/image.png?resize=350%2C200&ssl=1 1x, https:\/\/i0.wp.com\/allphasepharma.com\/dir\/wp-content\/uploads\/2025\/07\/image.png?resize=525%2C300&ssl=1 1.5x, https:\/\/i0.wp.com\/allphasepharma.com\/dir\/wp-content\/uploads\/2025\/07\/image.png?resize=700%2C400&ssl=1 2x"},"classes":[]},{"id":2435,"url":"https:\/\/allphasepharma.com\/dir\/2016\/04\/17\/2435\/the-brave-new-world-of-infectious-diseases\/","url_meta":{"origin":1840,"position":5},"title":"The Brave New World of Infectious Diseases","author":"Harald","date":"April 17, 2016","format":false,"excerpt":"Coming back from ECCMID, one\u00a0gets the impression that we are moving towards an era in which\u00a0we can diagnose everything but treat nothing. A late breaker session on colistin resistance provided much detail data on the situation in the EU. As we know, colistin resistance conferred by the mcr-1 gene has\u2026","rel":"","context":"In &quot;The News&quot;","block_context":{"text":"The News","link":"https:\/\/allphasepharma.com\/dir\/category\/the_news\/"},"img":{"alt_text":"ECCMID slider","src":"https:\/\/i0.wp.com\/allphasepharma.com\/dir\/wp-content\/uploads\/2016\/04\/ECCMID-slider.jpg?resize=350%2C200","width":350,"height":200,"srcset":"https:\/\/i0.wp.com\/allphasepharma.com\/dir\/wp-content\/uploads\/2016\/04\/ECCMID-slider.jpg?resize=350%2C200 1x, https:\/\/i0.wp.com\/allphasepharma.com\/dir\/wp-content\/uploads\/2016\/04\/ECCMID-slider.jpg?resize=525%2C300 1.5x"},"classes":[]}],"jetpack_likes_enabled":true,"_links":{"self":[{"href":"https:\/\/allphasepharma.com\/dir\/wp-json\/wp\/v2\/posts\/1840","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/allphasepharma.com\/dir\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/allphasepharma.com\/dir\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/allphasepharma.com\/dir\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/allphasepharma.com\/dir\/wp-json\/wp\/v2\/comments?post=1840"}],"version-history":[{"count":11,"href":"https:\/\/allphasepharma.com\/dir\/wp-json\/wp\/v2\/posts\/1840\/revisions"}],"predecessor-version":[{"id":1853,"href":"https:\/\/allphasepharma.com\/dir\/wp-json\/wp\/v2\/posts\/1840\/revisions\/1853"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/allphasepharma.com\/dir\/wp-json\/wp\/v2\/media\/1847"}],"wp:attachment":[{"href":"https:\/\/allphasepharma.com\/dir\/wp-json\/wp\/v2\/media?parent=1840"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/allphasepharma.com\/dir\/wp-json\/wp\/v2\/categories?post=1840"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/allphasepharma.com\/dir\/wp-json\/wp\/v2\/tags?post=1840"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}