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To theEditor—We thank Livorsi and Eckerle [1] for their comments on our meta-analysis and for sharing their local microbiology and outcomes data for healthcare associated pneumonia (HCAP) [1]. Their data illustrate several key points that arose from our meta-analysis and previous work [2, 3]. The first is the importance of knowing the local epidemiologic and microbiologic features of pneumonia rather than relying on a universal HCAP definition. Even allowing for the difficulties in obtaining a positive microbiologic diagnosis, their frequency of Enterobacteriaceae (38%), Pseudomonas aeruginosa (15%), and methicillin-resistant Staphylococcus aureus (MRSA; 12%) are extremely high, and therefore their local ecology is clearly different from that for recent European cohorts with reported rates of 2.2%–4.8% for P. aeruginosa, 1.6%–2.4% for MRSA, and 6.7%–7.2% for Enterobacteriaceae [2–5]. Even within the same country, such as the United States, very different rates of multidrug-resistant pathogens (MDR) are being reported. In their analysis, Livorsi and Eckerle do not report the rates of potentially resistant pathogens in their community-acquired pneumonia (CAP) population. Another key finding in our meta-analysis was that several studies reporting high rates of MDR pathogens in patients with HCAP also reported high rates in those with CAP [6]. A lack of discrimination between the 2 groups suggests the need for a better way of identifying patients at risk of MDR pathogens [7].

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