Severe Legionnaires' disease refractory to azithromycin: Are quinolones superior to macrolides?

Legionnaires' disease is typically treated with either a macrolide or fluoroquinolone. Antimicrobial sensitivity testing of clinical samples is not routinely done because Legionella is difficult to culture. Controlled trials to suggest non-inferiority of either class are limited. We present a case of a 43-year-old immunosuppressed man with severe Legionella pneumonia whose clinical course was complicated by persistent fevers, acute metabolic encephalopathy, septic shock, rhabdomyolysis, and acute kidney injury while on azithromycin. He rapidly improved after a switch to levofloxacin. The current guidelines recommend either using a quinolone or macrolide for Legionella pneumonia. However, there are conflicting data suggestive of a benefit of quinolones over macrolides. Our case prompts the question of optimal antibiotic choice in cases of severe Legionnaires' disease in immunocompromised patients and highlights the need for randomized controlled trials for further guidance.