To the Editor: Dr Brunkhorst and colleagues1 demonstrated that, among adult patients with severe sepsis, treatment with combined meropenem and moxifloxacin compared with meropenem alone did not result in less organ failure, as measured by Sequential Organ Failure Assessment scores compared between the 2 groups.
We believe that the study had a flaw in its design. Patients with severe community-acquired pneumonia were included in the study. Because all patients were treated in intensive care units, 50.3% had a community-acquired infection and 40.7% had pneumonia. Treatment of patients with severe community-acquired pneumonia with meropenem monotherapy contrasts with the guideline recommendations. Broad-spectrum coverage in the form of an intravenous macrolide or respiratory fluoroquinolone plus a non–pseudomonal third-generation cephalosporin, a β-lactam inhibitor, or a β-lactamase inhibitor, if Pseudomonas aeruginosa is not an issue, is recommended.2- 3 The addition of a macrolide or respiratory fluoroquinolone is aimed at covering atypical pathogens, namely Legionella pneumophilia, Mycoplasma pneumoniae, and Chlamydia pneumoniae. Evidence exists that failure to cover atypical pathogens is associated with treatment failure and even death.4 Therefore, inclusion of patients with severe community-acquired pneumonia in the study might put these patients at risk of inadequate empirical antibiotic therapy against atypical pathogens, which may lead to poor clinical outcomes. As a result, we suggest that a subgroup analysis in patients with severe community-acquired pneumonia is warranted.