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Catia Cillóniz, PhD; Antoni Torres, PhD, FCCP
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From the Department of Respiratory Diseases (Drs Cillóniz and Torres), Instituto del Tórax, Hospital Clínic de Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona; and Centro de Investigación Biomédica en Red Enfermedades Respiratorias (Drs Cillóniz and Torres).

Correspondence to: Antoni Torres, PhD, Department of Pneumology, Hospital Clinic of Barcelona, Calle Villarroel 170, Barcelona, Spain; e-mail: atorres@clinic.ub.es


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;144(6):1976. doi:10.1378/chest.13-1832
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To the Editor:

We 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.”

We are not aware of any CAP study having > 75% etiologies. This is impossible for the following reasons: (1) Blood cultures are poorly sensitive, (2) sputum is often unavailable or contaminated, (3) bronchoscopies cannot be performed in many patients, (4) patients are lost in follow-up (for serologies), and (5) polymerase chain reaction techniques are still not available for all microorganisms and all hospitals. Having said that, we believe that our results are very representative of CAP microbiology in patients older than 65 years of age, given the high number of patients included (2,149).

We do not think that our recommendation will increase the number of antibiotics administered. In fact, we believe the opposite will occur because we restricted our recommendations to (and only included) patients older than 65 years of age.

Finally, we doubt sincerely that site of care is the best approach for empirical treatment in CAP. In fact, patients in the ward who should be admitted to the ICU (particularly with Pneumonia Severity Index V2) from the beginning can frequently be observed. Instead, we believe that we have to move forward to treat patients empirically according to severity scales.3 We thank Dr Postma and colleagues again for their interest in our article.

References

Cillóniz C, Polverino E, Ewig S, et al. Impact of age and comorbidity on etiology and outcome in community-acquired pneumonia. Chest. 2013;144(3):999-1007. [CrossRef] [PubMed]
 
Valencia M, Badia JR, Cavalcanti M, et al. Pneumonia severity index class V patients with community-acquired pneumonia: characteristics, outcomes, and value of severity scores. 2007. Chest. 2009;136(5_suppl):e30. [CrossRef] [PubMed]
 
Cillóniz C, Ewig S, Polverino E, et al. Microbial aetiology of community-acquired pneumonia and its relation to severity. Thorax. 2011;66(4):340-346. [CrossRef] [PubMed]
 

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References

Cillóniz C, Polverino E, Ewig S, et al. Impact of age and comorbidity on etiology and outcome in community-acquired pneumonia. Chest. 2013;144(3):999-1007. [CrossRef] [PubMed]
 
Valencia M, Badia JR, Cavalcanti M, et al. Pneumonia severity index class V patients with community-acquired pneumonia: characteristics, outcomes, and value of severity scores. 2007. Chest. 2009;136(5_suppl):e30. [CrossRef] [PubMed]
 
Cillóniz C, Ewig S, Polverino E, et al. Microbial aetiology of community-acquired pneumonia and its relation to severity. Thorax. 2011;66(4):340-346. [CrossRef] [PubMed]
 
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