Dr. Pries raises the topic of pneumococcal vaccination: Approximately 40–50% percent of cases of community-acquired pneumonia (CAP) are caused by Streptococcus pneumoniae. With regard to this vaccination, there is conflicting evidence. The available 23-valent polysaccharide vaccine appears to be capable of lowering the number of cases with invasive pneumococcal disease (IPD) among young healthy adults. Unfortunately, the preventative effect cannot be reliably demonstrated for elderly and chronically-ill patients. Likewise, the available evidence does not show that this vaccine prevents pneumonias in general (all-cause pneumonia) – at least not in high-income countries. Also, meta-analyses found no reduction in overall mortality (1, 2).
Its indication is a subject of international controversy. The Standing Committee on Immunization of the Robert Koch Institute (STIKO) has so far maintained its general recommendation of vaccinating individuals older than 60 years. With regard to the issue of revaccination, the available evidence from studies is also difficult: The effect of revaccination is generally weaker than that of the primary vaccination and often minor, especially among the elderly; marked local reactions have also been reported. Consequently, it is not currently possible to issue recommendations for or against pneumococcal vaccination. Dr. Pries is right to draw our attention to ongoing studies. Here we would like to emphasize that the presented guideline is focused on the symptom “cough” and not on the comprehensive description of the various causative diseases. For CAP, a special S3 guideline is available. However, we will raise the issue again in our next update and address potentially available new evidence.
At the heart of the guideline, there is the recommendation to avoid any antibiotic treatment of uncomplicated upper respiratory tract infections which is not indicated. Concerning this, Dr. Feldmann notes that in most cases a bacterial superinfection is involved, recognizable by the presence of yellow-green sputum. However, this is not supported by epidemiological microbiological data: Although bacteria can indeed be detected in approximately 10–50% of patients with bronchitis (depending on the study), the marker “yellow sputum“ is not a good predictor for bacterial involvement in cough associated with common cold (positive predictive value (PPV) = 16%—see the paper of Altiner et al. (2009) cited in our article). Here, the paradigm “pus = bacteria“ does simply not apply.
But even more important is: Even if there is bacterial (co-) involvement with the bronchitis, the disease is typically harmless and self-limiting in otherwise healthy individuals. In cases with yellow sputum, the outcome is by no means worse, even without antibiotic treatment; bronchitis does certainly not progress regularly to pneumonia (3). As explained in the guideline, the benefit in time (faster complete healing) resulting from antibiotic intervention is marginal (4) and does not justify the routine use of antibiotics.
Dr. med. Felix Holzinger MPH
Institut für Allgemeinmedizin
Charité – Universitätsmedizin Berlin
Conflict of interest statement
The authors of all contributions declare that no conflict of interest exists.
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