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Antimicrobial Chemotherapy for Legionnaires Disease: Time for a Change

Paul H. Edelstein, MD
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University of Pennsylvania Medical Center; Philadelphia, PA 19104-4283 Note: Dr. Edelstein has received funding for research and related academic purposes from manufacturers of both macrolide and quinolone antibiotics. Acknowledgment: The author thanks Richard D. Meyer for reviewing the manuscript and suggesting changes. Requests for Reprints: Paul H. Edelstein, MD, Clinical Microbiology Laboratory, 4 Gates, University of Pennsylvania Medical Center, 3400 Spruce Street, Philadelphia, PA 19104-4283; e-mail, phe@mail.med.upenn.edu.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1998;129(4):328-330. doi:10.7326/0003-4819-129-4-199808150-00012
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Erythromycin became the de facto standard of treatment for Legionnaires disease soon after the first recognized epidemic of this disease occurred 22 years ago [12]. However, it is now time for a change in therapy because of increasing evidence of the superiority of newer antimicrobial agents. The conclusion that erythromycin is the drug of choice for Legionnaires disease was based on unavoidably imperfect retrospective analysis of treatment outcomes from the epidemic, which showed the lowest overall fatality rates with either erythromycin or tetracycline therapy. No prospective comparative studies with adequate statistical power of the treatment of Legionnaires disease have been published. Because of the relative rarity of Legionnaires disease and its widely varying outcomes, it is unlikely that an adequate comparative clinical trial of the disease will ever be completed; such a study would need to have 300 to 900 patients with the disease in each experimental group to have adequate statistical power [3]. This means that decisions about new therapy must be based on laboratory experiments and limited clinical data.

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