Etiology and therapy of community-acquired pneumonia

Burden of pneumococcal disease among adults in Southern Europe (Spain, Portugal, Italy, and Greece): a systematic review and meta-analysis

The aim was to summarize pneumococcal disease burden data among adults in Southern Europe and the potential impact of vaccines on epidemiology. Of 4779 identified studies, 272 were selected. Invasive pneumococcal disease (IPD) incidence was 15.08 (95% CI 11.01-20.65) in Spain versus 2.56 (95% CI 1.54-4.24) per 100,000 population in Italy. Pneumococcal pneumonia incidence was 19.59 (95% CI 10.74-35.74) in Spain versus 2.19 (95% CI 1.36-3.54) per 100,000 population in Italy. Analysis of IPD incidence in Spain comparing pre-and post- PCV7 and PCV13 periods unveiled a declining trend in vaccine-type IPD incidence (larger and statistically significant for the elderly), suggesting indirect effects of childhood vaccination programme. Data from Portugal, Greece and, to a lesser extent, Italy were sparse, thus improved surveillance is needed. Pneumococcal vaccination uptake, particularly among the elderly and adults with chronic and immunosuppressing conditions, should be improved, including shift to a higher-valency pneumococcal conjugate vaccine when available.

Community-acquired pneumonia: aetiology, antibiotic resistance and prospects of phage therapy

Bacteria are the most common aetiological agents of community-acquired pneumonia (CAP) and use a variety of mechanisms to evade the host immune system. With the emerging antibiotic resistance, CAP-causing bacteria have now become resistant to most antibiotics. Consequently, significant morbimortality is attributed to CAP despite their varying rates depending on the clinical setting in which the patients being treated. Therefore, there is a pressing need for a safe and effective alternative or supplement to conventional antibiotics. Bacteriophages could be a ray of hope as they are specific in killing their host bacteria. Several bacteriophages had been identified that can efficiently parasitize bacteria related to CAP infection and have shown a promising protective effect. Thus, bacteriophages have shown immense possibilities against CAP inflicted by multidrug-resistant bacteria. This review provides an overview of common antibiotic-resistant CAP bacteria with a comprehensive summarization of the promising bacteriophage candidates for prospective phage therapy.

Guidelines for the management of adult lower respiratory tract infections--summary

This document is an update of Guidelines published in 2005 and now includes scientific publications through to May 2010. It provides evidence-based recommendations for the most common management questions occurring in routine clinical practice in the management of adult patients with LRTI. Topics include management outside hospital, management inside hospital (including community-acquired pneumonia (CAP), acute exacerbations of COPD (AECOPD), acute exacerbations of bronchiectasis) and prevention. The target audience for the Guideline is thus all those whose routine practice includes the management of adult LRTI.

Guidelines for the management of adult lower respiratory tract infections--full version

This document is an update of Guidelines published in 2005 and now includes scientific publications through to May 2010. It provides evidence-based recommendations for the most common management questions occurring in routine clinical practice in the management of adult patients with LRTI. Topics include management outside hospital, management inside hospital (including community-acquired pneumonia (CAP), acute exacerbations of COPD (AECOPD), acute exacerbations of bronchiectasis) and prevention. Background sections and graded evidence tables are also included. The target audience for the Guideline is thus all those whose routine practice includes the management of adult LRTI.

A multicenter, open-label, randomized comparison of levofloxacin and azithromycin plus ceftriaxone in hospitalized adults with moderate to severe community-acquired pneumonia

BACKGROUND

Changing etiologic patterns and the growing problem of antimicrobial resistance, particularly an increase in macrolide-resistant pneumococcal bacteremia, are causing physicians to adopt new approaches to the treatment of community-acquired pneumonia (CAP).

OBJECTIVE

The relative efficacy and tolerability of levofloxacin monotherapy and azithromycin and ceftriaxone combination therapy were assessed in hospitalized adults with moderate to severe CAP.

METHODS

This Phase IV, multicenter, open-label, randomized trial compared 2 treatment regimens: (1) levofloxacin 500 mg PO or IV q24h, and (2) azithromycin 500 mg IV q24h for > or = 2 days plus ceftriaxone 1 g IV q24h for 2 days, followed by an optional transition to azithromycin 500 mg PO q24h at the investigator's discretion. The total duration of therapy was to be a minimum of 10 days in both treatment groups. Ceftriaxone was included in the initial azithromycin regimen to ensure coverage against pneumococcal bacteremia.

RESULTS

Of 236 patients in the intent-to-treat population, completion or withdrawal information was available for 110 patients in the levofloxacin group and 114 in the azithromycin group. Baseline demographic and disease characteristics were comparable between groups. At the end of treatment, the clinical success rate (cured + improved) in clinically evaluable patients was 94.1% in the levofloxacin group and 92.3% in the azithromycin group. The respective posttherapy microbiologic eradication rates were 89.5% and 92.3%. Levofloxacin was as well tolerated as azithromycin, with an incidence of drug-related adverse events (AEs) for all body systems of 5.3% and 9.3%, respectively. None of the drug-related AEs were considered serious [corrected].

CONCLUSIONS

In this study in hospitalized patients with moderate to severe CAP, levofloxacin monotherapy was at least as effective as a combination regimen of azithromycin and ceftriaxone in providing coverage against the current causative pathogens in CAP. In addition, levofloxacin was as well tolerated as the combination of azithromycin and ceftriaxone.

Evaluation of the clinical microbiology profile of moxifloxacin

Moxifloxacin is a new broad-spectrum antibacterial agent for treatment of respiratory tract infection of pathogens, including the major pathogens isolated in respiratory tract infections. The pharmacokinetic and pharmacodynamic properties of moxifloxacin are: excellent bioavailability, long half-life, and superior tissue penetration. Consequently, the 90% minimum inhibitory concentration (MIC(90)) values exhibited by moxifloxacin are generally lower than the concentrations of moxifloxacin found in circulation and in pulmonary tissues after a standard 400-mg dose given for up to 30 h. The relationship between moxifloxacin MIC(90) values and clinical response was investigated. The results of 13 clinical trials, performed in 30 countries between 1997 and 1998 and comprising 2618 patients treated with moxifloxacin or a comparator drug, were reviewed. Overall, 94% clinical success and 95% bacterial eradication was observed with moxifloxacin. These results were equivalent or superior to results seen with the comparator drugs. Clinical response rates and bacterial eradication rates with moxifloxacin were not significantly affected by bacterial resistance to other antibiotics (i.e., penicillin, clarithromycin, or amoxicillin). The majority (89%-97%) of the different bacterial strains with MICs for moxifloxacin < or =2 mg/L were successfully eradicated. In conclusion, moxifloxacin has potent in vivo bactericidal activity, and pathogen sensitivity to moxifloxacin is in accordance with US Food and Drug Administration and European suggested breakpoint values.

Sparfloxacin versus clarithromycin in the treatment of community-acquired pneumonia

Community-acquired pneumonia remains a significant health concern despite the availability of effective antibiotics. This randomized, double-masked, double-dummy, multicenter comparative trial was undertaken to compare the efficacy and safety of sparfloxacin with those of clarithromycin in the treatment of community-acquired pneumonia. In 54 centers throughout the United States, 342 patients aged > or = 18 years with community-acquired pneumonia were enrolled in this trial. A total of 167 patients, 98 males and 69 females with a mean age of 51.0 years (range, 18-87), received a 400-mg loading dose of sparfloxacin on the first day, followed by 200 mg once daily for a total of 10 days. A total of 175 patients, 85 males and 90 females with a mean age of 51.3 years (range, 18-91), received clarithromycin 250 mg twice daily for 10 days. In the intent-to-treat population, 133 (79.6%) patients in the sparfloxacin group and 145 (82.9%) in the clarithromycin group were cured or improved (the 95% confidence interval [CI] for the differences in success rate between sparfloxacin and clarithromycin was -11.5% to 5.1%). Success rates for the per-protocol patients were 88.7% (133/150) in the sparfloxacin group and 88.9% (144/162) in the clarithromycin groups (95% CI, -7.2% to 6.8%). There were no significant differences in success rate between treatment groups based on age > or = 65 years. The overall bacteriologic response rates in the bacteriologically assessable population were 97.0% (64/66 isolates) in the sparfloxacin group and 91.4% (74/81 isolates) in the clarithromycin group. Recurrence occurred in 6.0% of per-protocol patients in the sparfloxacin group and 6.3% of patients in the clarithromycin group. The overall frequency of adverse events was 56.3% in the sparfloxacin group and 65.1% in the clarithromycin group. Gastrointestinal disturbances were the most common adverse event in both groups. Abnormal taste related to study drug was reported by 17 patients (9.7%) treated with clarithromycin, versus 3 patients (1.8%) treated with sparfloxacin (P = 0.002). Photosensitivity reactions were reported in 10 patients (6.0%) treated with sparfloxacin, versus 1 patient (0.6%) treated with clarithromycin (P = 0.002). QT-interval prolongation was documented in 4 patients (2.4%) in the sparfloxacin group and no patients in the clarithromycin group. Thus sparfloxacin was as well tolerated and as effective as clarithromycin in the treatment of community-acquired pneumonia.

Cefepime versus ceftriaxone for empiric treatment of hospitalized patients with community-acquired pneumonia. The Cefepime Study Group

Effective empiric treatment of pneumonia requires antibiotic coverage against gram-negative and gram-positive pathogens, including drug-resistant isolates. We compared the safety and efficacy of intravenous (i.v.) cefepime (2 g administered every 12 h) to those of i.v. ceftriaxone (1 g administered every 12 h) for the empiric treatment of hospitalized patients with community-acquired pneumonia. Of the 115 patients randomized to the study, 86 (cefepime recipients, n = 40; ceftriaxone recipients, n = 46) were evaluated for clinical efficacy (clinically evaluated patients). Favorable clinical outcomes (cure or improvement) were comparable among clinically evaluated patients in the cefepime and ceftriaxone treatment arms (95.0 versus 97.8%, respectively; 95% confidence interval for treatment difference [data for ceftriaxone group minus data for cefepime group], -5.1 to +10.8%). The most common bacteria isolated from patients in both treatment groups were Streptococcus pneumoniae, Haemophilus influenzae, and Staphylococcus aureus. In clinically evaluated patients with a microbiologic response, all (100%) of the 32 pathogens from cefepime-treated patients and 97.4% (38 of 39) of the pathogens from ceftriaxone-treated patients were eradicated (documented or presumed eradication). The one persistent infection in the ceftriaxone group was caused by Pseudomonas fluorescens. Both treatments were well tolerated. Our data thus suggest that cefepime and ceftriaxone have comparable safety and efficacy for the treatment of pneumonia in hospitalized patients.