Archive for April 5, 2015

How good is the evidence for the recommended empirical antimicrobial treatment of patients hospitalized because of community-acquired pneumonia? A systematic review.

J Antimicrob Chemother. 2003 Oct;52(4):555-63.

Oosterheert JJ1, Bonten MJ, Hak E, Schneider MM, Hoepelman IM.

1Division of Medicine, Department of Acute Medicine and Infectious Diseases, University Medical Centre Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands. j.j.oosterheert@azu.nl

Abstract

BACKGROUND:

For years, monotherapy with a beta-lactam antibiotic (penicillin, amoxicillin or second-generation cephalosporin) was recommended as empirical therapy for patients with community-acquired pneumonia (CAP). A combination of a beta-lactam and a macrolide antibiotic was only recommended for patients with severe CAP needing intensive care treatment or when atypical pathogens, i.e. Legionella pneumophila, Mycoplasma pneumoniae and Chlamydia pneumoniae, were strongly suspected. However, new guidelines recommend a combination of a beta-lactam antibiotic plus a macrolide or monotherapy with a fluoroquinolone for all patients hospitalized with CAP. We evaluated whether treatment with a beta-lactam plus macrolide or quinolone monotherapy is truly superior to beta-lactam treatment alone.

METHODS:

We systematically reviewed available studies, retrieved from MEDLINE and by hand-searching reference lists from recent reviews and guidelines on the effectiveness of recommended empirical antimicrobial treatment of patients hospitalized because of CAP.

RESULTS:

Eight relevant studies were selected. In six studies significant reductions in mortality were found, in one study a reduction in hospital length of stay was found and in one study no beneficial effects could be demonstrated for treatment regimens with fluoroquinolone monotherapy or combinations of beta-lactams and macrolides. The beneficial value of macrolides or fluoroquinolones might be the result of a large and mainly unrecognized role of atypical pathogens in the aetiology of CAP, anti-inflammatory effects of macrolides or resistance to beta-lactams of the most important pathogens. However, the studies supporting the recommended treatment regimen were designed as non-experimental cohort studies. As a consequence, the results may have been influenced by confounding by indication. In addition, the outcomes showed several inconsistencies.

CONCLUSIONS:

A randomized controlled trial is warranted to circumvent the methodological flaws in the designs of the currently available studies. Since the addition of macrolides or treatment with fluoroquinolones may lead to enhanced antibiotic resistance, increased side effects and healthcare-related costs, such a fundamental change in the treatment of CAP should be based on valid data.

PDF

http://jac.oxfordjournals.org/content/52/4/555.full.pdf+html

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April 5, 2015 at 10:00 pm

A review of Streptococcus pneumoniae infection treatment failures associated with fluoroquinolone resistance.

Clin Infect Dis. 2005 Jul 1;41(1):118-21.

BRIEF REPORT

Fuller JD1, Low DE.

1Department of Microbiology, Toronto Medical Laboratories and Mount Sinai Hospital, Toronto, Ontario, Canada.

Abstract

We reviewed all of the published reports of cases of fluoroquinolone treatment failures for respiratory tract infection due to fluoroquinolone-resistant Streptococcus pneumoniae.

There were 20 ciprofloxacin and levofloxacin treatment failures reported.

Physicians should be aware, when treating pneumococcal respiratory tract infections in older patients with a fluoroquinolone, that clinical failures might occur, especially for patients with comorbid illnesses and a history of recent fluoroquinolone use.

PDF

http://cid.oxfordjournals.org/content/41/1/118.full.pdf+html

April 5, 2015 at 9:57 pm

SWAB/NVALT (Dutch Working Party on Antibiotic Policy and Dutch Association of Chest Physicians) guidelines on the management of community-acquired pneumonia in adults.

Neth J Med. 2012 Mar;70(2):90-101.

Wiersinga WJ1, Bonten MJ, Boersma WG, Jonkers RE, Aleva RM, Kullberg BJ, Schouten JA, Degener JE, Janknegt R, Verheij TJ, Sachs AP, Prins JM; Dutch Working Party on Antibiotic Policy; Dutch Association of Chest Physicians.

1Department of Internal Medicine, University of Amsterdam, Amsterdam, the Netherlands. w.j.wiersinga@amc.uva.nl

Abstract

The Dutch Working Party on Antibiotic Policy (SWAB) and the Dutch Association of Chest Physicians (NVALT) convened a joint committee to develop evidence-based guidelines on the diagnosis and treatment of community acquired pneumonia (CAP).

The guidelines are intended for adult patients with CAP who present at the hospital and are treated as outpatients as well as for hospitalised patients up to 72 hours after admission.

Areas covered include current patterns of epidemiology and antibiotic resistance of causative agents of CAP in the Netherlands, the possibility to predict the causative agent of CAP on the basis of clinical data at first presentation, risk factors associated with specific pathogens, the importance of the severity of disease upon presentation for choice of initial treatment, the role of rapid diagnostic tests in treatment decisions, the optimal initial empiric treatment and treatment when a specific pathogen has been identified, the timeframe in which the first dose of antibiotics should be given, optimal duration of antibiotic treatment and antibiotic switch from the intravenous to the oral route.

Additional recommendations are made on the role of radiological investigations in the diagnostic work-up of patients with a clinical suspicion of CAP, on the potential benefit of adjunctive immunotherapy, and on the policy for patients with parapneumonic effusions.

PDF

http://www.njmonline.nl/getpdf.php?id=1155

April 5, 2015 at 9:55 pm

BTS guidelines for the management of community acquired pneumonia in adults: update 2009.

Thorax. 2009 Oct;64 Suppl 3:iii1-55.

Lim WS1, Baudouin SV, George RC, Hill AT, Jamieson C, Le Jeune I, Macfarlane JT, Read RC, Roberts HJ, Levy ML, Wani M, Woodhead MA; Pneumonia Guidelines Committee of the BTS Standards of Care Committee.

Collaborators (36)

Author information

1Respiratory Medicine, Nottingham University Hospitals, David Evans Building, Hucknall Road, Nottingham NG5 1PB, UK. weishen.lim@nuh.nhs.uk

FULL TEXT

http://thorax.bmj.com/content/64/Suppl_3/iii1.long

PDF

http://thorax.bmj.com/content/64/Suppl_3/iii1.full.pdf+html

April 5, 2015 at 9:52 pm


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