819

Role of Atypical Pathogens in the Etiology of

Community-Acquired Pneumonia
Forest W. Arnold, DO, MSc1 James T. Summersgill, PhD1 Julio A. Ramirez, MD1

1 Division of Infectious Diseases, School of Medicine, Address for correspondence Julio Ramirez, MD, University of
University of Louisville, Louisville, Kentucky Louisville, 501 E. Broadway, Suite 140 B, Louisville, KY 40202
(e-mail: Julio.Ramirez@louisville.edu).
Semin Respir Crit Care Med 2016;37:819828.

Abstract Atypical pneumonia has been described for over 100 years, but some of the pathogens
attributed to it have been identied only in the past decades. The most common
pathogens are Chlamydia pneumoniae, Mycoplasma pneumoniae, and Legionella pneumo-

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phila. The epidemiology and pathophysiology of these three pathogens have been
studied since their discovery, and are reviewed herein to provide better insight when
evaluating these patients, which hopefully translates into improved care. The incidence
of atypical pathogens has been shown to be approximately 22% worldwide, but this
probably varies with location. The history and physical exam of a patient with atypical
pneumonia reveals how patients share many signs and symptoms with their counterpart
patients who have typical pneumonias; therefore, the diagnosis primarily depends on
laboratory identication, which is evolving and improving. What started out as simple,
Keywords but difcult to yield cultures, has progressed to modern molecular-based testing assays.
atypical pneumonia Treatment is missed if an empiric regimen includes only monotherapy with a -lactam
Mycoplasma antimicrobial; so, many country guidelines, including the Infectious Diseases Society of
pneumoniae America/American Thoracic Society guidelines for community-acquired pneumonia,
Chlamydia recommend using a regimen containing either a macrolide or a uorinated quinolone.
pneumoniae Once an atypical pathogen has been identied, evidence trends toward favoring a
Legionella quinolone, but more data are needed to conrm. The concept of using combination
pneumophila therapy in severe patients is also explored.

Atypical pneumonia is an interesting entity because,
although it is not the most common lung disease, nor is it
the most deadly, it can produce signicant pathology and even
death in some circumstances. There have been varying
descriptions for atypical pneumonia; so, before describing
what part they play in the etiology of community-acquired
pneumonia (CAP), the denition of it needs to be claried. Its
understanding has actually evolved over time, as technology
has improved to provide more microbiological and clinical
information. After Streptococcus pneumoniae was discovered
in 1881, an atypical pathogen was considered to be one that did
not grow on blood agar. In the 1940s, once penicillin and
sulfonamides were widely used for CAP, an atypical pathogen
was considered to be one that did not respond to one of these
typical antibiotics. An early term was primary atypical
pneumonia, indicating that the cause was unknown or idio-
pathic.1 Primary atypical pneumonia presented as a headache
and malaise with fever and chills. Soon after those symptoms, a
dry, irritating cough developed with crackles on auscultation.
Then a cough was described as becoming productive, and the
fever remittent to as high as 104F. The chest radiograph,
however, provided more of the basis for the diagnosis at that
time than history or physical exam. At the same time, the
inltrate was described as a wedge shape from the perihilar
area to the periphery. An interstitial inltrate is the classic
appearance, but varying radiographic appearances are com-
mon. Presently, the term is casually used to refer to a CAP that
produces any unusual clinical symptoms, laboratory values, or

Issue Theme Community-Acquired Copyright 2016 by Thieme Medical DOI http://dx.doi.org/

Pneumonia: A Global Perspective; Guest Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0036-1592121.
Editors: Charles Feldman, MBBCh, DSc, New York, NY 10001, USA. ISSN 1069-3424.
PhD, FRCP, FCP (SA), and James D. Tel: +1(212) 584-4662.
Chalmers, MBChB, PhD, FRCPE
820 Role of Atypical Pathogens in the Etiology of CAP
Table 1 Microbiological organisms noted to be atypical
pathogens
Common bacterial pathogens
Mycoplasma pneumoniae
Legionella pneumophila
Chlamydia pneumoniae
Uncommon bacterial pathogens
Coxiella burnetii
Francisella tularensis
Other pathogens
Adenovirus
Bocavirus
Chlamydia psittaci
Cytomegalovirus
Inuenza virus
Metapneumovirus
Mycobacterium tuberculosis
Pneumocystis jirovecii
Respiratory syncytial virus
radiological appearances in a patient. There are evidenced-
based clinical differences which will be described later. For the
purposes of this article, an atypical pneumonia will be consid-
ered as a specic CAP due to one of the common bacterial
pathogens listed in Table 1: Chlamydia pneumoniae, Myco-
plasma pneumoniae, and Legionella pneumophila.
Historical Aspects
Before M. pneumoniae was discovered, Eaton et al discovered
a nondescript agent that caused pneumonia when exposed to
rodents, and that agent could be neutralized by serum from
patients who had had atypical pneumonia.2,3 It was not until

15 years later, however, that it was grown on cell-free
culture and produced the syndrome in volunteers.4 It was
in the intervening time that Finland et al realized that
exposing serum from patients with atypical pneumonia
agglutinated red blood cells when exposed to the cold
(4C), otherwise known as cold agglutinins.5
L. pneumophila was discovered in 1976 during the Penn-
sylvania State American Legion meeting in Philadelphia, PA.
Thirty-four people died as a result, and an epidemiological
study linked the deaths to a newly discovered pathogen,
L. pneumophila, which was found in the water vapor conden-
sate of the hotel air conditioner. Since that time it has been
attributed to several other outbreaks before and after that
time from varying water sources. The oldest unsolved out-
break was from 1957 at a meat packing plant where 78
workers acquired pneumonia, two of whom died.6 Once
L. pneumophila was discovered, antibody titers were obtained
from those who lived through the meat packing plant out-
Seminars in Respiratory and Critical Care Medicine Vol. 37 No. 6/2016
Arnold et al.
break and compared with 30 control patients. Titers of
1:  64 were in 80% of the workers, and 13% of the controls
supporting the cause of the outbreak to be Legionnaire
disease.
C. pneumoniae was rst discovered in 1965, and it was
frozen and reanalyzed in 1971 when better isolation methods
were available. Even then, however, it could only be described
by what it was not: neither C. trachomatis nor C. psittaci. In
1983, a student in Seattle had pharyngitis and the pathogen
was isolated, but it was not until sequence analysis and
morphology by electron microscopy were discovered that it
was identied as C. pneumoniae. It was designated as its own
species in 1989. In 1999, Chlamydia was changed to Chlamy-
dophila based on ribosomal RNA gene sequences, but contro-
versy remains regarding the reclassication with publications
still using both names.7
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Epidemiology
M. pneumoniae is probably the cause of more atypical pneu-
monia than any other pathogen, and is transmitted by
respiratory droplets. Younger people (520 years of age)
have the highest attack rates, but it can occur in any age
group. Cases typically present individually, or further history
may reveal multiple family members with a similar syndrome
1 to 3 weeks apart, which matches its incubation period.
Some exposed family members who do not become ill may
have evidence of M. pneumoniae carriage. In one study, 4 of 71
(5%) household contacts of an index family member with M.
pneumoniae tested positive, but were asymptomatic.8 Other
studies have shown much higher carriage rates, such as 56% of
64 healthy children from Texas.9 Variation may depend on
carriage that lasts for approximately 4 months, and depends
on the time of year.10 Mini epidemics may also occur,
especially in military camps or schools.11 The largest outbreak
at a U.S. university in nearly 40 years occurred in Georgia in
2012. A total of 83 students were diagnosed; 12 of 19 tested
positive.12 M. pneumoniae causes colonization and disease,
especially among children.
Of the common bacterial pathogens listed in Table 1,
L. pneumophila is the most severe because it has the highest
severity of disease and quickest onset of illness. The incuba-
tion period is 1 to 28 days with most occurring between 4 and
6 days. It is transmitted from the environment by an infec-
tious aerosol, typically by anything that sprays a mist of water.
There are other rare, water-related cases.13 There is no
person-to-person transmission. It presents sporadically
and in epidemics. The incidence reported by the CDC is
0.4/100,000 population, but most are not diagnosed because
a polymerase chain reaction (PCR) test or urine antigen test
are not performed. Those patients are usually treated empiri-
cally with success. In light of under-reported cases, a lack of
complete surveillance, and considering that prospective
studies report additional cases, an incidence of approximately
8/100,000 population is more realistic.14 The incidence is
certainly higher among patients with CAP. A study from Spain
with 15 years of data from almost 4,000 CAP patients starting
in 1995 reported 5% with L. pneumophila.15
 Role of Atypical Pathogens in the Etiology of CAP
C. pneumoniae has a high seroprevalence rate compared
with its rate of causing disease. Serologic studies evaluating
IgG antibodies in the general population detected C. pneumo-
niae in approximately 50% of adults.16 The rates were quite
low in children before school age, but then elevated briskly
after that, and continued to rise into elderly ages, implying
that people continue to have reinfections over time. In a
recent study from Jordan, seroprevalence of 190 patients was
compared between a group with CAP and a control group.17
Rates were some of the highest in the world at 70% for CAP
patients and 61% for controls. For titers above 1:512 (the
highest positive dilution and considered in the study to be a
sign of acute infection because convalescent titers were not
feasible), the rates were 16% for those with CAP, and 5% for the
controls; p 0.036. Incidentally, the authors described
limitations using the PCR, as it showed no difference in the
population because 16% were positive in CAP patients and
19% were positive in control patients (p 0.56).
The incidence of atypical pathogens, C. pneumoniae,
L pneumophila, and M. pneumoniae, has been studied in
different regions among patients with CAP. Two Spanish
studies found higher rates of atypical pathogens in outpa-
tients compared with inpatients; 36 versus 16%, respectively,
in one study and 67 versus 31% in the other.18,19 A small Israeli
study of 126 patients found atypical bacteria in 52% of CAP
patients.20 Three Chinese studies combined to study 2,407
patients of whom 40% had CAP due to an atypical patho-
gen.2123 A study from Chile, a region not previously known
to have signicant rates of atypical bacteria, found the
prevalence of atypical bacteria to be 22% among 356
patients.24
Our experience stems from the Division of Infectious
Diseases, the University of Louisville, serving as a reference
Fig. 1 Regions of the community-acquired pneumonia organization and world incidence of atypical pneumonia.
Arnold et al. 821
laboratory receiving samples from all over the world for
atypical pathogen PCR analysis.25 From 1996 to 2004, a total
of 4,337 patients were studied and categorized into four
regions (Fig. 1). Most patients were from North America,
followed by Europe, Latin America, and Asia/Africa. Overall
incidence was 22% worldwide with M. pneumoniae account-
ing for approximately 50% of those, C. pneumoniae 30%, and
L. pneumophila 20%. There appears to be a trend, even in the
past 15 years, from atypical pathogens representing a minor-
ity of patient etiologies with CAP to a higher proportion. The
high rates of M. pneumoniae found in China may correspond
to the extremely high rates of macrolide-resistant M. pneu-
moniae, as high as 97%.26 The macrolide-resistant M. pneumo-
niae rate was reported to be 30% in Israel,27 10% in France,28
and 13% in the United States.29
A recent prospective study seeking to determine the
etiology of each hospitalized patient enrolled with CAP was
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conducted in ve hospitals in Chicago, IL, and Nashville, TN,
from 2010 to 2012.30 A thorough work-up for the etiology
was performed on each patient including sputum and blood
samples for bacteria, paired acute-phase and convalescent-
phase serum for viruses, urine for L. pneumophila and
S. pneumoniae, nasopharyngeal and oropharyngeal samples
for viruses, as well as bronchoalveolar lavage (BAL), pleural
uid, and endotracheal aspirate samples for bacteria, fungi,
and mycobacteria when obtained for clinical care. Among
2,259 patients, 966 samples were positive in 853 (38%)
patients. S. pneumoniae was not the most common pathogen
as it has been in years of preceding prospective and retro-
spective studies. Rather, human rhinovirus was the most
common pathogen with 194 (9%) positive results, inuenza
A or B was second with 132 (6%) positive results, and
S. pneumoniae was third with 115 (5%) positive results.
Seminars in Respiratory and Critical Care Medicine Vol. 37 No. 6/2016
822 Role of Atypical Pathogens in the Etiology of CAP
Clinical Features
Mycoplasma pneumoniae
M. pneumoniae presents insidiously with a cough, fever,
headache, and general malaise. It is known as walking
pneumonia as it is commonly not severe, which allows
many patients to carry on their usual activities of daily living.
A chest radiograph may have a sparse opacity. If tracheo-
bronchitis develops, it is usually in children and when
pneumonia develops, it is usually in adults. Fevers may rise
to 101 or 102F while the cough worsens. M. pneumoniae has
a strong afnity for respiratory epithelial cells causing des-
quamation of ciliated epithelial cells and cessation of tracheal
ciliary action, thus resulting in persistent cough, occasionally
with paroxysms. Physical exam may reveal mild tachypnea
and scattered rhonchi. There can be extrapulmonary signs as
well. Erythema multiforme is the most common dermato-
logic manifestation. When present it is manifested by vesicles
and larger bullae, especially at mucocutaneous junctions.
StevensJohnsons syndrome is obviously more severe, but
fortunately more rare with M. pneumoniae. Raynauds phe-
nomenon is technically a vasospasm entity, but is recognized
by examining the skin. Though there is no proof, it seems
logical to associate it with the action of cold agglutinins. In
patients who develop high agglutinin titers, and who have
sickle cell disease or hemoglobinopathies, digital necrosis
may occur. A Gram stain of sputum reveals leukocytes, but
bacteria are not visible because M. pneumoniae lack a cell wall
to retain Gram stain. Overall, the diagnosis relies on other
laboratory tests for conrmation.
Legionella pneumophila
The classical signs and symptoms of infection with L. pneumo-
phila include a fever with a pulse-temperature dissociation and
hyponatremia with some combination of nonproductive cough,
diarrhea, confusion, myalgia, elevated transaminases, and hypo-
phosphatemia. But studies have failed to nd distinguishing
clinical characteristics between typical and atypical pneumo-
nias. One study evaluated fever, tachypnea, headache, and the
absence of purulent sputum, as well as hyponatremia and found
no difference with multivariate analysis.31 The attempt to nd
differentiating clinical features in children was also unsuccess-
ful.32 Regardless, the symptoms do occur, but without specifying
the etiology of the syndrome. The prodrome of symptoms
includes headache, myalgia, asthenia, and anorexia followed
by fever, diarrhea, and abdominal pain. The cough becomes
productive in approximately half of patients. The chest radio-
graph is similar to CAP due to S. pneumoniae (Fig. 2). Similar to
the clinical symptoms, hyponatremia does not single out a
L. pneumophila patient. In one study,33 the sodium (mmol/L)
and standard deviation for patients with L. pneumophila com-
pared with other etiologies was 132.7  4.9 versus 135.7  5.1.
Although these values were statistically different, they are not
clinically different. Systemic or extrapulmonary symptoms may
be more impressive than local pulmonary symptoms. It is when
those symptoms are severe that they are most noticeable, such as
a fever above 102F and bradycardia (not associated with a pacer
or medication), headache (with cognitive impairment or
Seminars in Respiratory and Critical Care Medicine Vol. 37 No. 6/2016
Arnold et al.
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Fig. 2 Chest radiograph of patient with Legionnaire disease resem-
bling community-acquired pneumonia due to Streptococcus
pneumoniae.
encephalopathy), or abdominal pain that is acute. In the decade
that followed its discovery, L. pneumophila was diagnosed in
infections of the skin, soft tissue, surgical wounds, every major
organ, bone, and the lymphatic system.3436
Chlamydia pneumoniae
Lower respiratory tract infections, especially pneumonia, are
the most common presentations of C. pneumoniae, while
upper respiratory infections, such as sinusitis and pharyngitis
are less common, but do occur. Initial symptoms may be
rhinorrhea, sore throat, and hoarseness (but not fever), which
then diminish followed gradually by cough and shortness of
breath. Pneumonia symptoms occur, but are not specic.37
The initial symptoms may last for days or weeks, but it is the
lower respiratory tract symptoms that usually cause a patient
to present for medical care; so, the time from duration to
presentation is longer with C. pneumoniae. A chest radiograph
is similar to other pneumonias (typical and atypical) and so,
while it supports a diagnosis of pneumonia, it does not
suggest an etiology. Leukocytosis is not common. Cough
and malaise may last for weeks or months, even though
appropriate antimicrobial treatment was prescribed. Extrap-
ulmonary systems reported with C. pneumoniae have includ-
ed the cardiac, nervous, and the integumentary systems. Most
extrapulmonary study has been invested in C. pneumoniae-
infected atherosclerotic cardiovascular disease. The patho-
physiology of atherosclerotic disease involves inammation,
and it is reasonable to consider that if a pathogen is present
within a plaque, then it has a role in the process. We have
harvested plaques from arteries during heart transplant
surgeries and identied C. pneumoniae in the plaques,38
but have not determined whether it contributed to the
presence of the plaque or not.
 Role of Atypical Pathogens in the Etiology of CAP
Relevance of the Atypical Pathogen Life Cycle
Mycoplasma pneumoniae
M. pneumoniae is the smallest self-replicating organism, and
is also a parasite. It lacks a cell wall, but has an organelle,
which binds to host epithelial cells (Fig. 3A). Once inside the
host cell, it undergoes binary ssion to replicate.39 It has a
short genome and engages in limited metabolic activity of its
own. It scavenges for cholesterol for its cell membrane, and
nucleic acid precursors for its DNA. Because it has no cell wall,
it has no target for -lactams, and therefore must be treated
with a different antimicrobial.
Legionella pneumophila
L. pneumophila has a porin on its surface, which is an outer
membrane protein to which complement components bind to
alveolar macrophages and thus expedite phagocyte opsoni-
zation, a process of surrounding and taking L. pneumophila
inside the phagocyte (Fig. 3B). The C3 component of com-
plement promotes phagocytosis while suppressing oxidative
burst. Lysosomes within phagocytes typically release acids
that degrade engulfed particles, but L. pneumophila avoids
fusing with them, so death does not occur. L. pneumophila
ultimately lls the host phagosome until it is in a agellated
form and escapes the phagocyte by causing apoptosis and
necrosis so that it may infect other phagocytes.
Chlamydia pneumoniae
C. pneumoniae is able to live independently of its host and
does so in a small elementary body. It then attaches to an
alveolar macrophage and then gains entry inside in an
inclusion, where it remains until it is later released
(Fig. 3C). Before that can happen, it changes into a larger,
noninfectious reticulate body with more periplasmic space.
The reticulate bodies mature into elementary bodies and
eventually extrude out of the cell, sometimes lysing it, in
search of a new host cell.
Fig. 3 (A) Mycoplasma pneumoniae binds to host epithelial cells where it demonstrates scavenges for cellular components to undergo binary
ssion to reproduce. (B) Legionella pneumoniae gain access inside alveolar macrophages via opsonization. (C) Chlamydia pneumoniae enter alveolar
macrophages as small elementary bodies, transform into larger reticulate bodies, and replicate and mature into elementary bodies before lysing
out of the host cell.
Arnold et al. 823
Evolution of Diagnostic Tests for Atypical
Pneumonia
Culture has served as the original gold standard for the
isolation of L. pneumophila, M. pneumoniae, and C. pneumoniae
since their discovery as agents of pneumonia in humans.
L. pneumophila was originally isolated in pure culture on
Meuller-Hinton agar supplemented with IsoVitaleX.40 However,
buffered charcoal yeast extract agar (BCYE)41 was later used as a
more dened medium, and continues to be the preferred choice
today. Acid pretreatment42 is usually used to increase recovery of
L. pneumophila from heavily contaminated specimens such as
sputum. M. pneumoniae has typically been isolated on pleuro-
pneumonia-like organism (PPLO) agar,43 whereas C. pneumoniae
requires the use of cell culture (e.g., human laryngeal tumor cells
[HEp2 cells])44 to adequately propagate the organism in pure
culture. However, sensitivity of culture for the isolation of these
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agents is less than desirable, falling in the 50 to 60% range,
depending on the agent.45
Direct detection of L. pneumophila in clinical samples, such
as sputum, BAL, and tissue specimens, was achieved by the
introduction of the direct uorescent antibody (DFA) assay in
1979.46 The sensitivity of DFA is typically low, approximately
25 to 50%, but if positive, it can provide a rapid diagnosis. The
use of monoclonal antibody-based DFA reagents can reduce
background uorescence47 and thus increase specicity of
testing. Rapid direct antigen detection of either M. pneumo-
niae or C. pneumoniae in clinical specimens has limited value
in diagnosis of acute disease.
Serologic assays aimed at detection of circulating anti-
bodies to L. pneumophila, M. pneumoniae, or C. pneumoniae
have been used, in various forms, for many years now. The
indirect uorescent antibody (IFA) assay for L. pneumophila
antibodies48 was described in 1979 and used to dene break-
points for positivity. A fourfold increase in titer to a level of at
least 1:128 was required to be considered positive. The
micro-immunouorescence antibody (MIF) assay was
Seminars in Respiratory and Critical Care Medicine Vol. 37 No. 6/2016
824 Role of Atypical Pathogens in the Etiology of CAP
described by Wang49 in 1971 and provided a valuable screen-
ing method for the incidence and epidemiology of C. pneumo-
niae infection. For many years, the presence of cold-
agglutinins,50 or a complement xation assay, was used as
a proxy for infection with M. pneumoniae.51 However, these
assays suffered from a lack of sensitivity and specicity, and
was therefore replaced by more sensitive assays such as the
enzyme-linked immunosorbent assay (ELISA)-based specic
antibody detection systems and indirect IFA assays. Signi-
cantly elevated IgM titers for M. pneumoniae or C. pneumoniae
can indicate acute infection; however, a fourfold rise in either
IgM or IgG titer52 is needed to conrm active disease with
either of these agents.
Taking advantage of the excretion of L. pneumophila
serogroup 1-specic antigen in the urine of infected patients,
early on, several methods were developed to detect these
antigens, including latex agglutination,53 ELISA,54 and radio-
immunoassay.55 ELISA-based systems, made commercially
available by Binax, Inc. (Portland, ME) have evolved into a
rapid, lateral ow, immunochromatographic (lateral ow)
assay, useful as point-of-care tests to rapidly detect antige-
nuria. These are 15-minute tests based on the presence or
absence of a colored line on a test strip. Although these tests
have become a valuable tool, one inherent shortcoming is its
limitation of detecting only Lp serogroup 1 antigenuria, and
thus not useful in the diagnosis of any other species or
serogroups of L. pneumophila that are implicated in human
disease. Antigen-detection assays have also been reported for
M. pneumoniae infection, and include a lateral ow test,
plus more sophisticated platforms, such as nanorod array
surface-enhanced Raman spectroscopy (NA-SERS), and
matrix-assisted laser desorption/ionization time-of-ight
mass spectrometry (MALDI-TOF MS).56 These methods are
also useful in tracking macrolide-resistant M. pneumoniae, as
noted particularly important in some Asian countries.
As might be expected, diagnosis of infection with atypical
agents of CAP turned early on to molecular methods as the test of
choice, as they offered increased sensitivity and specicity when
compared with nonmolecular methods. Edelstein57 reported in
1986 the use of a radio-labeled DNA probe to detect 156
L. pneumophila sp. strains. This assay was later successfully
marketed by Gen-Probe, Inc. (San Diego, CA) as a commercially
available kit. In 1990, Mahbubani et al58 described a PCR assay
for the detection of environmental isolates of L. pneumophila,
utilizing a 5S rRNA gene as the target sequence. Ramirez et al59
used this gene as a target for the development of a clinical assay
for the diagnosis of L. pneumophila pneumonia in throat swab
specimens from patients with CAP. In the interceding years,
additional reports of molecular-based assays for the detection of
L. pneumophila in several different clinical samples were
reported. For example, successful use of PCR for L. pneumophila
in BAL specimens was described by Jaulhac et al60 in 1992 using
the macrophage infectivity protein gene (mip) as the target
sequence, and by Jonas et al in 199561 targeting a 16S rRNA
sequence. The mip gene was used to detect L. pneumophila in
sputum62 and in serum63 specimens from CAP patients.
A PCR-based assay for the detection of M. pneumoniae in
throat swab specimens was initially described by Bernet et al64
Seminars in Respiratory and Critical Care Medicine Vol. 37 No. 6/2016
Arnold et al.
in 1989 who targeted an ATPase operon gene, and by Jensen
et al65 who utilized the P1 attachment gene in throat swabs
specimens. Between 1989 and 2003, no less than 35 in-house
molecular assays appeared in the literature for the detection of
M. pneumoniae. Clinical specimens ranged from throat swabs,
nasopharyngeal swabs, sputum, BAL, trans-tracheal aspirates,
and lung biopsy. A radio-labeled, DNA-probe assay was
marketed by GenProbe, Inc. (San Diego, CA) in the late
1980s, and was useful in detecting this organism in throat
swab, and other specimen types. These original methods have
more recently evolved into assays based on a series of molec-
ular platforms, including real-time PCR; multiplexed, real-time
PCR; and isothermal amplication methods, such as nucleic
acid sequence-based amplication66 and loop-mediated
isothermal amplication.67
Holland et al68 described a PCR-based assay for C. pneumoniae
in 1990, targeting the major outer membrane protein, followed
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by Campbell et al69 in 1992, who utilized a cloned restriction
endonuclease, Pst1 fragment, as the target sequence. In 1992,
Gaydos et al70 described a PCR-based assay, along with an
enzyme-immunoassay conrmation step, targeting a 16S
rRNA gene sequence, followed by a series of reports evaluating
its clinical utility.71 Like that seen with M. pneumoniae detection,
no less than 20 reports appeared in the literature between 1990
and 2000. The CDC convened a workshop and settled on ve in-
house developed assays that were considered validated72 and
urged the use of these in research studies. Subsequently, several
additional platforms were used to detect C. pneumoniae in
clinical samples, including ligase chain reaction,73 and strand
displacement amplication assay.
The culmination of molecular-based testing for the atypi-
cal agents occurred with the development and marketing of
two FDA-cleared assays. The FilmArray Respiratory Panel
(Biore Diagnostics, Salt Lake City, UT) is a rapid (
1 hour),
multiplexed assay that detects 20 respiratory pathogens. The
list includes 17 viral targets and 3 bacterial targets in naso-
pharyngeal swabs. M. pneumoniae and C. pneumoniae, along
with Bordetella pertussis, are the bacterial agents included in
the assay. Testing is conducted in a single, pouch-based
system; however, a newer format is available, allowing the
ability to link several individual tests together for batch
testing of specimens. More recently, the NxTag Respiratory
Pathogen Panel, manufactured by Luminex, Inc. (Austin, TX),
has received FDA clearance, and tests for 18 viral pathogens,
along with M. pneumoniae and C. pneumoniae in nasopha-
ryngeal swab specimens. This test is conducted in a 96-well
format, allowing for batch testing of specimens.
Treatment for Atypical Pneumonia
The treatment options for atypical bacteria were erythromy-
cin or doxycycline until uorinated quinolones were released.
It was the result of a study by Critchley et al, released in 2002,
which represents how uorinated quinolones are a modern-
day treatment option for the three primary atypical patho-
gens (C. pneumoniae, L. pneumophila, and M. pneumoniae).74
The study evaluated in vitro activity of levooxacin against
nine isolates of C. pneumoniae, 146 isolates of L. pneumophila,
 Role of Atypical Pathogens in the Etiology of CAP
and 41 isolates of M. pneumoniae from six European countries
and the United States. The authors described potent activity
against L. pneumophila with levooxacin (MIC90 0.03 mg/L),
which had 15-fold activity over erythromycin (MIC90 0.5 mg/L),
and 65-fold activity over doxycycline (MIC90 2 mg/L). Subse-
quently, the macrolide, solithromycin, was also shown to
have potent activity against L. pneumophila with an MIC90 of
0.03 mg/L.75 Although two of the isolates by Critchley et al
were macrolide resistant, azithromycin had much more
potency based on MIC90 (0.0005 mg/L) than levooxacin
(1 mg/L). The study also showed activity for C. pneumoniae,
which supported previous research showing the ability of a
quinolone to retain antimicrobial activity after penetrating
an infected host cell. These are some of the studies support-
ing macrolide and quinolone effectiveness when treating
atypical pathogens.
Although -lactams are not effective against atypical
pathogens, in a study of 214 patients, 24 (11%) did not receive
a macrolide, quinolone, or tetracycline.15 They had acute
onset of illness (p 0.004), pleuritic chest pain (p 0.03),
and pleural effusion (p 0.05) compared with those who
received appropriate treatment.
There were seven studies after 2002 that compared levo-
oxacin to a macrolide for treatment of L. pneumophila. Three
Spanish studies in 2005 showed some degree of benet of a
quinolone, but they compared the quinolone to an older
macrolide (erythromycin or clarithromycin). In an outbreak
of 292 patients in Murcia, Spain, those who were treated with
levooxacin and who were more seriously ill had fewer
complications and a shorter length of hospital stay than those
who were treated with clarithromycin.76 In less ill patients,
there was no difference. A retrospective, observational study
in Barcelona, Spain, including 139 patients, evaluated time to
clinical stability and length of hospital stay.77 Patients who
received levooxacin stabilized after an average of 3 days
compared with those who received clarithromycin or eryth-
romycin who took 5 days (p 0.002). Furthermore, the
average hospital stay for the quinolone group was 8 days
and for the macrolide group it was 10 days; p 0.014. An
observational study in Badalona, Spain, reviewed 130 pa-
tients and evaluated time to defervescence, length of hospital
stay, and mortality, but only found a statistical difference for
levooxacin and a shorter time to defervescence, approxi-
mately 3 days compared with 2 days.78
Four other studies found no statistical difference when
treating atypical pneumonia with a quinolone or macrolide. A
prospective, observational study in Barcelona compared 113
patients divided among three treatmentsazithromycin,
clarithromycin, or levooxacin.79 They evaluated mortality,
length of hospital stay, and duration of fever. The quinolone
arm having only 18 patients may have accounted for the lack
of signicant difference. A study from Japan was smaller, and
found no differences when comparing the unique outcomes
of time of decline of leukocytes and C-reactive protein, and
duration of fever between ciprooxacin and erythromycin.80
Two other studies were equivocal, but had outcome results
that trended toward statistical signicance. An international
observational study compared levooxacin treatment to
Arnold et al. 825
macrolide treatment (azithromycin or clarithromycin) in 39
patients.81 Mean length of hospital stay for the levooxacin
group was 8.9 days versus 12.7 days for the macrolide group
(p 0.43). Mean time to clinical stability was 4.3 days versus
5.1 days, respectively (p 0.10). One patient in each group
died. The nal study was from Barcelona, which reviewed 214
patients with L. pneumophila.15 The median length of hospital
stay for levooxacin versus a macrolide was 3 versus 5 days,
respectively (p 0.09). The median time to clinical stability
was signicant at 7 versus 10 days, respectively
(p < 0.001).
There have been some data published regarding combina-
tion macrolide and quinolone therapy for patients with L.
pneumophila.82 In one case series of 22 patients, there was a
statistically signicant difference for those who received
combination therapy for improving leukocytes, C-reactive
protein, pO2/FiO2 ratio, and chest radiograph score at
Downloaded by: State University of New York at Stony Brook. Copyrighted material.
7 days, but not at 3 days. Time to defervescence was not
signicant at either time point.
Clinicians may not struggle with which drug to use once
the diagnosis of atypical pneumonia is veried, as they do
with what antimicrobial regimen to use with empirically. The
Infectious Diseases Society of America/American Thoracic
Society guidelines83 for CAP recommend a regimen with
either a macrolide or a quinoloneboth covering atypical
pathogens. Some European guidelines do not always recom-
mend an antimicrobial regimen that covers atypical patho-
gens.84 A meta-analyses of 16 observational studies favored
combination -lactam and macrolide therapy over -lactam
therapy alone.85 Combination therapy (covering atypical
pathogens) had reduced mortality (adjusted odds ratio:
0.67, 95% condence interval: 0.610.73, p < 0.001). A pro-
spective study randomized patients to receive either a -
lactam with a macrolide or a -lactam alone to measure if
there was a difference in time to clinical stability.86 The result
was a nonsignicant 7%. Although the authors based their
estimation of what number of patients would be needed to
show a signicant difference between times to clinical stabil-
ity, the actual proportion was much different, and their power
was suboptimal as a result. Their study, however, could be
used to generate a more accurate number of patients needed
to enroll to show a statistical signicance. Based on these
studies, at this time the standard of care in the United States
and many other countries remains to cover atypical patho-
gens when empirically covering for CAP.
Conclusion
With data, albeit limited, showing that atypical pneumonia
affects approximately one in every ve patients with CAP, it
should be considered whenever evaluating a patient with a
pneumonia syndrome. Although most outpatients could
eventually recover from M. pneumoniae without treatment,
improved morbidity is a welcome relief to those with persis-
tent signs and symptoms (e.g., fever and cough) who are given
the correct treatment. For inpatients with atypical pneumo-
nia, especially L. pneumophila, correct treatment has been
shown to improve early outcomes and mortality. Checking for
Seminars in Respiratory and Critical Care Medicine Vol. 37 No. 6/2016
826 Role of Atypical Pathogens in the Etiology of CAP
atypical pneumonia by performing a throat swab to detect
PCR at the time of starting empiric treatment provides
valuable information to further care for those who develop
a prolonged course, and provides diagnostic feedback for
those who recover.
Funding
None.
Acknowledgments
The authors appreciate Timothy Wiemken, PhD, Assistant
Professor of Medicine, and Kimberly Buckner, BA, Clinical
Research Coordinator, Division of Infectious Diseases, Uni-
versity of Louisville School of Medicine, for technical
assistance.
References
1 Dingle JH. Primary atypical pneumonia. Am J Public Health Nations
Health 1944;34(4):347357
2 Eaton MD, Meiklejohn G, van Herick W, Corey M. Studies on the
etiology of primary atypical pneumonia: II. properties of the virus
isolated and propagated in chick embryos. J Exp Med 1945;82(5):
317328
3 Eaton MD, van Herick W, Meiklejohn G. Studies on the etiology of
primary atypical pneumonia: III specic neutralization of the virus
by human serum. J Exp Med 1945;82(5):329342
4 Chanock RM, Rifkind D, Kravetz HM, Kinght V, Johnson KM.
Respiratory disease in volunteers infected with Eaton agent: a
preliminary report. Proc Natl Acad Sci U S A 1961;47:887890
5 Finland M, Peterson OL, Allen HE, Samper BA, Barnes MW, Stone
MB. Cold agglutinins. I occurrence of cold isohemagglutinins in
various conditions. J Clin Invest 1945;24(4):451457
6 Osterholm MT, Chin TD, Osborne DO, et al. A 1957 outbreak of
Legionnaires disease associated with a meat packing plant. Am J
Epidemiol 1983;117(1):6067
7 Stephens RS, Myers G, Eppinger M, Bavoil PM. Divergence without
difference: phylogenetics and taxonomy of Chlamydia resolved.
FEMS Immunol Med Microbiol 2009;55(2):115119
8 Dorigo-Zetsma JW, Wilbrink B, van der Nat H, Bartelds AI, Heijnen
ML, Dankert J. Results of molecular detection of Mycoplasma
pneumoniae among patients with acute respiratory infection
and in their household contacts reveals children as human reser-
voirs. J Infect Dis 2001;183(4):675678
9 Wood PR, Hill VL, Burks ML, et al. Mycoplasma pneumoniae in
children with acute and refractory asthma. Ann Allergy Asthma
Immunol 2013;110(5):328334.e1
10 Spuesens EB, Fraaij PL, Visser EG, et al. Carriage of Mycoplasma
pneumoniae in the upper respiratory tract of symptomatic and
asymptomatic children: an observational study. PLoS Med 2013;
10(5):e1001444
11 Mogabgab WJ. Mycoplasma pneumoniae and adenovirus respira-
tory illnesses in military and university personnel, 1959-1966. Am
Rev Respir Dis 1968;97(3):345358
12 Centers for Disease Control and Prevention (CDC). Mycoplasma
pneumoniae outbreak at a university - Georgia, 2012. MMWR
Morb Mortal Wkly Rep 2013;62(30):603606
13 Nozue T, Chikazawa H, Miyanishi S, et al. Legionella pneumonia
associated with adult respiratory distress syndrome caused
by Legionella pneumophila serogroup 3. Intern Med 2005;
44(1):7378
Seminars in Respiratory and Critical Care Medicine Vol. 37 No. 6/2016
Arnold et al.
14 Marston BJ, Plouffe JF, File TM Jr, et al; The Community-Based
Pneumonia Incidence Study Group. Incidence of community-
acquired pneumonia requiring hospitalization. Results of a popu-
lation-based active surveillance Study in Ohio. Arch Intern Med
1997;157(15):17091718
15 Viasus D, Di Yacovo S, Garcia-Vidal C, et al. Community-acquired
Legionella pneumophila pneumonia: a single-center experience
with 214 hospitalized sporadic cases over 15 years. Medicine
(Baltimore) 2013;92(1):5160
16 Grayston JT. Infections caused by Chlamydia pneumoniae strain
TWAR. Clin Infect Dis 1992;15(5):757761
17 Al-Aydie SN, Obeidat NM, Al-Younes HM. Role of Chlamydia
pneumoniae in community-acquired pneumonia in hospitalized
Jordanian adults. J Infect Dev Ctries 2016;10(3):227236
18 Cillniz C, Ewig S, Polverino E, et al. Microbial aetiology of
community-acquired pneumonia and its relation to severity.
Thorax 2011;66(4):340346
19 Capelastegui A, Espaa PP, Bilbao A, et al; Poblational Study of
Pneumonia (PSoP) Group. Etiology of community-acquired pneu-
Downloaded by: State University of New York at Stony Brook. Copyrighted material.
monia in a population-based study: link between etiology and
patients characteristics, process-of-care, clinical evolution and
outcomes. BMC Infect Dis 2012;12:134
20 Shibli F, Chazan B, Nitzan O, et al. Etiology of community-acquired
pneumonia in hospitalized patients in northern Israel. Isr Med
Assoc J 2010;12(8):477482
21 Tao LL, Hu BJ, He LX, et al. Etiology and antimicrobial resistance of
community-acquired pneumonia in adult patients in China. Chin
Med J (Engl) 2012;125(17):29672972
22 Chen K, Jia R, Li L, Yang C, Shi Y. The aetiology of community
associated pneumonia in children in Nanjing, China and aetio-
logical patterns associated with age and season. BMC Public Health
2015;15:113
23 Liu Y, Chen M, Zhao T, et al. Causative agent distribution and
antibiotic therapy assessment among adult patients with commu-
nity acquired pneumonia in Chinese urban population. BMC Infect
Dis 2009;9:31
24 Luchsinger V, Ruiz M, Zunino E, et al. Community-acquired
pneumonia in Chile: the clinical relevance in the detection of
viruses and atypical bacteria. Thorax 2013;68(11):10001006
25 Arnold FW, Summersgill JT, Lajoie AS, et al; Community-Acquired
Pneumonia Organization (CAPO) Investigators. A worldwide per-
spective of atypical pathogens in community-acquired pneumo-
nia. Am J Respir Crit Care Med 2007;175(10):10861093
26 Zhou Y, Zhang Y, Sheng Y, Zhang L, Shen Z, Chen Z. More
complications occur in macrolide-resistant than in macrolide-
sensitive Mycoplasma pneumoniae pneumonia. Antimicrob
Agents Chemother 2014;58(2):10341038
27 Averbuch D, Hidalgo-Grass C, Moses AE, Engelhard D, Nir-Paz R.
Macrolide resistance in Mycoplasma pneumoniae, Israel, 2010.
Emerg Infect Dis 2011;17(6):10791082
28 Peuchant O, Mnard A, Renaudin H, et al. Increased macrolide
resistance of Mycoplasma pneumoniae in France directly detected
in clinical specimens by real-time PCR and melting curve analysis.
J Antimicrob Chemother 2009;64(1):5258
29 Zheng X, Lee S, Selvarangan R, et al. Macrolide-resistant Myco-
plasma pneumoniae, United States. Emerg Infect Dis 2015;21(8):
14701472
30 Jain S, Self WH, Wunderink RG, et al; CDC EPIC Study Team.
Community-acquired pneumonia requiring hospitalization
among U.S. adults. N Engl J Med 2015;373(5):415427
31 Masi M, Gutirrez F, Padilla S, et al. Clinical characterisation of
pneumonia caused by atypical pathogens combining classic and
novel predictors. Clin Microbiol Infect 2007;13(2):153161
32 Korppi M, Don M, Valent F, Canciani M. The value of clinical
features in differentiating between viral, pneumococcal and atyp-
ical bacterial pneumonia in children. Acta Paediatr 2008;97(7):
943947
 Role of Atypical Pathogens in the Etiology of CAP
33 Fernndez JA, Lpez P, Orozco D, Merino J. Clinical study of an
outbreak of Legionnaires disease in Alcoy, Southeastern Spain. Eur
J Clin Microbiol Infect Dis 2002;21(10):729735
34 Watts JC, Hicklin MD, Thomason BM, Callaway CS, Levine AJ. Fatal
pneumonia caused by Legionella pneumophila, serogroup 3: dem-
onstration of the bacilli in extrathoracic organs. Ann Intern Med
1980;92(2 Pt 1):186188
35 Evans CP, Winn WC Jr. Extrathoracic localization of Legionella
pneumophila in Legionnaires pneumonia. Am J Clin Pathol
1981;76(6):813815
36 Edelstein PH, Roy CR. Legionnaires disease. In: Bennett JE, Dolin R,
Blaser MJ, eds. Mandell, Douglas and Bennetts Principles and
Practice of Infectious Diseases. Philadelphia, PA: WB Saunders;
2015:26332644
37 Kauppinen MT, Saikku P, Kujala P, Herva E, Syrjl H. Clinical
picture of community-acquired Chlamydia pneumoniae pneumo-
nia requiring hospital treatment: a comparison between chlamyd-
ial and pneumococcal pneumonia. Thorax 1996;51(2):185189
38 Borel N, Summersgill JT, Mukhopadhyay S, Miller RD, Ramirez JA,
Pospischil A. Evidence for persistent Chlamydia pneumoniae infec-
tion of human coronary atheromas. Atherosclerosis 2008;199(1):
154161
39 Waites KB, Talkington DF. Mycoplasma pneumoniae and its role as
a human pathogen. Clin Microbiol Rev 2004;17(4):697728
40 Feeley JC, Gorman GW, Weaver RE, Mackel DC, Smith HW. Primary
isolation media for Legionnaires disease bacterium. J Clin Micro-
biol 1978;8(3):320325
41 Phillips E, Nash P. Culture media. In: Lennette EH, Balows A,
Hausler WJ, Shadomy HJ, eds. Manual of Clinical Microbiology.
Washington, DC: American Society for Microbiology; 1985:
10511092
42 Buesching WJ, Brust RA, Ayers LW. Enhanced primary isolation of
Legionella pneumophila from clinical specimens by low-pH treat-
ment. J Clin Microbiol 1983;17(6):11531155
43 Dajani AS, Clyde WA Jr, Denny FW. Experimental infection with
Mycoplasma pneumonia (Eatons Agent). J Exp Med 1965;121(6):
10711086
44 Roblin PM, Dumornay W, Hammerschlag MR. Use of HEp-2 cells
for improved isolation and passage of Chlamydia pneumoniae.
J Clin Microbiol 1992;30(8):19681971
45 Ieven M, Ursi D, Van Bever H, Quint W, Niesters HG, Goossens H.
Detection of Mycoplasma pneumoniae by two polymerase chain
reactions and role of M. pneumoniae in acute respiratory tract
infections in pediatric patients. J Infect Dis 1996;173(6):
14451452
46 Cherry WB, Pittman B, Harris PP, et al. Detection of Legionnaires
disease bacteria by direct immunouorescent staining. J Clin
Microbiol 1978;8(3):329338
47 Edelstein PH, Beer KB, Sturge JC, Watson AJ, Goldstein LC. Clinical
utility of a monoclonal direct uorescent reagent specic for
Legionella pneumophila: comparative study with other reagents.
J Clin Microbiol 1985;22(3):419421
48 Nagington J, Wreghitt TG, Tobin JO, Macrae AD. The antibody
response in Legionnaires disease. J Hyg (Lond) 1979;83(2):
377381
49 Wang SP, Grayston JT, Alexander ER, Holmes KK. Simplied micro-
immunouorescence test with trachoma-lymphogranuloma ve-
nereum (Chlamydia trachomatis) antigens for use as a screening
test for antibody. J Clin Microbiol 1975;1(3):250255
50 Ferriman D. Cold agglutinins in atypical pneumonia. Lancet 1947;
2(6462):34
51 Taylor-Robinson D, Somerson NL, Turner HC, Chanock RM. Sero-
logical relationships among human mycoplasmas as shown by
complement-xation and gel diffusion. J Bacteriol 1963;85:
12611273
52 Hindiyeh M, Carroll KC. Laboratory diagnosis of atypical pneumo-
nia. Semin Respir Infect 2000;15(2):101113
Arnold et al. 827
53 Sathapatayavongs B, Kohler RB, Wheat LJ, White A, Winn WC Jr.
Rapid diagnosis of Legionnaires disease by latex agglutination. Am
Rev Respir Dis 1983;127(5):559562
54 Berdal BP, Farshy CE, Feeley JC. Detection of Legionella pneumo-
nophila antigen in urine by enzyme-linked immunospecic assay.
J Clin Microbiol 1979;9(5):575578
55 Kohler RB, Zimmerman SE, Wilson E, et al. Rapid radioimmunoas-
say diagnosis of Legionnaires disease: detection and partial
characterization of urinary antigen. Ann Intern Med 1981;94(5):
601605
56 Diaz MH, Winchell JM. The evolution of advanced molecular
diagnostics for the detection and characterization of Mycoplasma
pneumoniae. Front Microbiol 2016;7:232
57 Edelstein PH. Evaluation of the Gen-Probe DNA probe for the
detection of legionellae in culture. J Clin Microbiol 1986;23(3):
481484
58 Mahbubani MH, Bej AK, Miller R, Haff L, DiCesare J, Atlas RM.
Detection of Legionella with polymerase chain reaction and gene
probe methods. Mol Cell Probes 1990;4(3):175187
Downloaded by: State University of New York at Stony Brook. Copyrighted material.
59 Ramirez JA, Ahkee S, Tolentino A, Miller RD, Summersgill JT.
Diagnosis of Legionella pneumophila, Mycoplasma pneumoniae,
or Chlamydia pneumoniae lower respiratory infection using the
polymerase chain reaction on a single throat swab specimen.
Diagn Microbiol Infect Dis 1996;24(1):714
60 Jaulhac B, Nowicki M, Bornstein N, et al. Detection of Legionella
spp. in bronchoalveolar lavage uids by DNA amplication. J Clin
Microbiol 1992;30(4):920924
61 Jonas D, Rosenbaum A, Weyrich S, Bhakdi S. Enzyme-linked
immunoassay for detection of PCR-amplied DNA of legionellae
in bronchoalveolar uid. J Clin Microbiol 1995;33(5):12471252
62 Koide M, Saito A. Diagnosis of Legionella pneumophila infection by
polymerase chain reaction. Clin Infect Dis 1995;21(1):199201
63 Lindsay DS, Abraham WH, Fallon RJ. Detection of mip gene by PCR
for diagnosis of Legionnaires disease. J Clin Microbiol 1994;
32(12):30683069
64 Bernet C, Garret M, de Barbeyrac B, Bebear C, Bonnet J. Detection of
Mycoplasma pneumoniae by using the polymerase chain reaction.
J Clin Microbiol 1989;27(11):24922496
65 Jensen JS, Sndergrd-Andersen J, Uldum SA, Lind K. Detection of
Mycoplasma pneumoniae in simulated clinical samples by poly-
merase chain reaction. Brief report. APMIS 1989;97(11):
10461048
66 Loens K, Ieven M, Ursi D, et al. Detection of Mycoplasma pneumo-
niae by real-time nucleic acid sequence-based amplication. J Clin
Microbiol 2003;41(9):44484450
67 Saito R, Misawa Y, Moriya K, Koike K, Ubukata K, Okamura N.
Development and evaluation of a loop-mediated isothermal
amplication assay for rapid detection of Mycoplasma pneumo-
niae. J Med Microbiol 2005;54(Pt 11):10371041
68 Holland SM, Gaydos CA, Quinn TC. Detection and differentiation of
Chlamydia trachomatis, Chlamydia psittaci, and Chlamydia pneu-
moniae by DNA amplication. J Infect Dis 1990;162(4):984987
69 Campbell LA, Perez Melgosa M, Hamilton DJ, Kuo CC, Grayston JT.
Detection of Chlamydia pneumoniae by polymerase chain reaction.
J Clin Microbiol 1992;30(2):434439
70 Gaydos CA, Quinn TC, Eiden JJ. Identication of Chlamydia pneu-
moniae by DNA amplication of the 16S rRNA gene. J Clin Micro-
biol 1992;30(4):796800
71 Gaydos CA, Eiden JJ, Oldach D, et al. Diagnosis of Chlamydia
pneumoniae infection in patients with community-acquired pneu-
monia by polymerase chain reaction enzyme immunoassay. Clin
Infect Dis 1994;19(1):157160
72 Dowell SF, Peeling RW, Boman J, et al; C. pneumoniae Workshop
Participants. Standardizing Chlamydia pneumoniae assays: recom-
mendations from the Centers for Disease Control and Prevention
(USA) and the Laboratory Centre for Disease Control (Canada). Clin
Infect Dis 2001;33(4):492503
Seminars in Respiratory and Critical Care Medicine Vol. 37 No. 6/2016
828 Role of Atypical Pathogens in the Etiology of CAP
73 Chernesky M, Smieja M, Schachter J, et al. Comparison of an
industry-derived LCx Chlamydia pneumoniae PCR research kit to
in-house assays performed in ve laboratories. J Clin Microbiol
2002;40(7):23572362
74 Critchley IA, Jones ME, Heinze PD, et al. In vitro activity of levooxacin
against contemporary clinical isolates of Legionella pneumophila,
Mycoplasma pneumoniae and Chlamydia pneumoniae from North
America and Europe. Clin Microbiol Infect 2002;8(4):214221
75 Van Bambeke F, Tulkens PM. The role of solithromycin in the
management of bacterial community-acquired pneumonia.
Expert Rev Anti Infect Ther 2016;14(3):311324
76 Blzquez Garrido RM, Espinosa Parra FJ, Alemany Francs L, et al.
Antimicrobial chemotherapy for Legionnaires disease: levoox-
acin versus macrolides. Clin Infect Dis 2005;40(6):800806
77 Mykietiuk A, Carratal J, Fernndez-Sab N, et al. Clinical outcomes
for hospitalized patients with Legionella pneumonia in the anti-
genuria era: the inuence of levooxacin therapy. Clin Infect Dis
2005;40(6):794799
78 Sabri M, Pedro-Botet ML, Gmez J, et al; Legionnaires Disease
Therapy Group. Fluoroquinolones vs macrolides in the treatment
of Legionnaires disease. Chest 2005;128(3):14011405
79 Falc V, Molina I, Juste C, et al. [Treatment for Legionnaires disease.
Macrolides or quinolones?] Enferm Infecc Microbiol Clin 2006;
24(6):360364
80 Haranaga S, Tateyama M, Higa F, et al. Intravenous ciprooxacin
versus erythromycin in the treatment of Legionella pneumonia.
Intern Med 2007;46(7):353357
Seminars in Respiratory and Critical Care Medicine Vol. 37 No. 6/2016
Arnold et al.
81 Grifn AT, Peyrani P, Wiemken T, Arnold F. Macrolides versus
quinolones in Legionella pneumonia: results from the Communi-
ty-Acquired Pneumonia Organization international study. Int J
Tuberc Lung Dis 2010;14(4):495499
82 Nakamura S, Yanagihara K, Izumikawa K, et al. The clinical efcacy
of uoroquinolone and macrolide combination therapy compared
with single-agent therapy against community-acquired pneumo-
nia caused by Legionella pneumophila. J Infect 2009;59(3):
222224
83 Mandell LA, Wunderink RG, Anzueto A, et al; Infectious Diseases
Society of America; American Thoracic Society. Infectious Diseases
Society of America/American Thoracic Society consensus guide-
lines on the management of community-acquired pneumonia in
adults. Clin Infect Dis 2007;44(Suppl 2):S27S72
84 Cavali P. Evolution of antibiotic consumption from 20002010 in
France. Bull Epidemiol Hebd [serial online] 2012;13:480484.
Available at: http://www.invs.sante.fr/Publications-et-outils/BEH-
Bulletin-epidemiologique-hebdomadaire/Archives/2012/BEH-n-
42-43-2012. Accessed May 10, 2016
Downloaded by: State University of New York at Stony Brook. Copyrighted material.
85 Nie W, Li B, Xiu Q. -Lactam/macrolide dual therapy versus
-lactam monotherapy for the treatment of community-acquired
pneumonia in adults: a systematic review and meta-analysis.
J Antimicrob Chemother 2014;69(6):14411446
86 Garin N, Genn D, Carballo S, et al. -Lactam monotherapy vs
-lactam-macrolide combination treatment in moderately severe
community-acquired pneumonia: a randomized noninferiority
trial. JAMA Intern Med 2014;174(12):18941901