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Israelsen SB, Tingsgård S, Thorlacius-Ussing L, Knudsen A, Lindegaard B, Johansen IS, Mygind LH, Ravn P, Benfield T. Short-course antibiotic therapy of 5 days in community-acquired pneumonia (CAP5): study protocol for a randomised controlled trial. BMJ Open 2023; 13:e069013. [PMID: 37479519 PMCID: PMC10364160 DOI: 10.1136/bmjopen-2022-069013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/23/2023] Open
Abstract
INTRODUCTION The optimal duration of antibiotic therapy for community-acquired pneumonia (CAP) is unsettled. Short-course therapy has proved successful in clinical trials but is not yet implemented in everyday clinical practice. Validation of results from randomised controlled trials is crucial to evaluate existing evidence and provide clinicians with assurance of using new treatment strategies. In a pragmatic framework, we aim to assess the use of short-course antibiotic therapy guided by the onset of clinical stability in patients hospitalised with CAP. METHODS AND ANALYSIS This study is a randomised controlled trial with a non-inferiority design that will examine the efficacy of short-course antibiotic therapy in patients hospitalised with CAP. From six hospitals across Denmark, we plan to enrol 564 patients between 2019 and 2024. Within 3-5 days after initiating antibiotic therapy, participants will be randomised 1:1 to parallel treatment arms: (1) short-course antibiotic therapy of 5 days or (2) antibiotic therapy of at least 7 days. The primary outcome will be 90-day readmission-free survival and will be estimated as an absolute risk difference with a predefined non-inferiority margin of -6%. Secondary outcomes will comprise other safety measures including new antibiotics, adverse events, length of hospital stay and postdischarge outpatient visits. Both intention-to-treat and per-protocol analyses will be performed. ETHICS AND DISSEMINATION This study has been approved by the Health Research Ethics Committee of the Capital Region of Denmark (identifier number: H-19014479). Trial data will be made available in anonymous form when the trial has ended. TRIAL REGISTRATION NUMBER NCT04089787, ClinicalTrials.Gov.
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Affiliation(s)
- Simone Bastrup Israelsen
- Department of Infectious Diseases, Copenhagen University Hospital, Amager and Hvidovre, Hvidovre, Denmark
| | - Sandra Tingsgård
- Department of Infectious Diseases, Copenhagen University Hospital, Amager and Hvidovre, Hvidovre, Denmark
| | - Louise Thorlacius-Ussing
- Department of Infectious Diseases, Copenhagen University Hospital, Amager and Hvidovre, Hvidovre, Denmark
| | - Andreas Knudsen
- Department of Respiratory Medicine and Infectious Diseases, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Birgitte Lindegaard
- Department of Respiratory Medicine and Infectious Diseases, Copenhagen University Hospital, North Zealand, Hillerød, Denmark
| | - Isik S Johansen
- Department of Infectious Diseases, Odense University Hospital, Odense, Denmark
| | - Lone Hagens Mygind
- Department of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark
| | - Pernille Ravn
- Department of Internal Medicine, Section for Infectious Diseases, Copenhagen University Hospital, Herlev and Gentofte, Hellerup, Denmark
| | - Thomas Benfield
- Department of Infectious Diseases, Copenhagen University Hospital, Amager and Hvidovre, Hvidovre, Denmark
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Jambo A, Edessa D, Adem F, Gashaw T. Appropriateness of antimicrobial selection for treatment of pneumonia in selected public hospitals of Eastern Ethiopia: A cross-sectional study. SAGE Open Med 2023; 11:20503121231163792. [PMID: 37065976 PMCID: PMC10102944 DOI: 10.1177/20503121231163792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 02/27/2023] [Indexed: 04/18/2023] Open
Abstract
Objective Inappropriate antimicrobial use leads to drug resistance and poor clinical outcomes. Considering the lack of data regarding the drug use patterns in the treatment of pneumonia in selected study areas, the authors felt compelled to assess the appropriateness of antimicrobial usage in the treatment of pneumonia at Hiwot Fana Specialized Comprehensive University Hospital and Jugal Hospital from May 1 to 31, 2021. Methods A cross-sectional retrospective study was conducted using the medical cards of 693 admitted patients with pneumonia. The collected data were analyzed using SPSS version 26. Bivariable and multivariable logistic regression analyses were used to identify the factors associated with an initial inappropriate antibiotic use. A p value of 0.05 was used to determine the statistical significance of the association using an adjusted odds ratio with 95% confidence interval. Results Of the total participants, 116 (16.74%, 95% confidence interval: 14.1-19.6) of them received an initial inappropriate antimicrobial regimen. Ceftriaxone plus azithromycin was the most prescribed antimicrobial agent. Patients who were younger than 5 years (adjusted odds ratio = 1.71; 95% confidence interval: 1.00-2.94), between 6 and 14 years (adjusted odds ratio = 3.14; 95% confidence interval: 1.64-6.00), and older than 65 years (adjusted odds ratio = 2.97; 95% confidence interval: 1.07-2.66), with comorbid conditions (adjusted odds ratio = 1.74; 95% confidence interval: 1.10-2.72) and prescribed by medical interns (adjusted odds ratio = 1.80; 95% confidence interval: 1.14-2.84) were associated with an initial inappropriate antimicrobial use. Conclusion Around one out of every six patients had received initial inappropriate treatments. Adherence to the recommendation of guidelines and attention to extreme-aged groups and comorbidity may improve antimicrobial use.
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Affiliation(s)
- Abera Jambo
- Clinical Pharmacy Department, School of
Pharmacy, College of Health and Medical Sciences, Haramaya University, Harar,
Ethiopia
- Abera Jambo, Clinical Pharmacy Department,
School of Pharmacy, College of Health and Medical Sciences, Haramaya University,
Harar, Ethiopia.
| | - Dumessa Edessa
- Clinical Pharmacy Department, School of
Pharmacy, College of Health and Medical Sciences, Haramaya University, Harar,
Ethiopia
| | - Fuad Adem
- Clinical Pharmacy Department, School of
Pharmacy, College of Health and Medical Sciences, Haramaya University, Harar,
Ethiopia
| | - Tigist Gashaw
- Department of Pharmacology and
Toxicology, School of Pharmacy, College of Health and Medical Sciences, Haramaya
University, Harar, Ethiopia
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Xu L, Wang C, Peng X, Jiao Y, Zhao C, Zhang L, Ma L. Empirical Antibiotic Treatment Strategies for Community-Acquired Pneumonia: A Network Meta-analysis. J Glob Antimicrob Resist 2022; 30:1-9. [DOI: 10.1016/j.jgar.2022.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 05/17/2022] [Accepted: 05/18/2022] [Indexed: 11/15/2022] Open
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Al-Salloum J, Gillani SW, Mahmood RK, Gulam SM. Comparative efficacy of azithromycin versus clarithromycin in combination with beta-lactams to treat community-acquired pneumonia in hospitalized patients: a systematic review. J Int Med Res 2021; 49:3000605211049943. [PMID: 34719987 PMCID: PMC8645313 DOI: 10.1177/03000605211049943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 09/08/2021] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE The objective was to compare the efficacy of azithromycin and clarithromycin in combination with beta-lactams to treat community-acquired pneumonia among hospitalized adults. METHODS Five databases (PubMed, Google Scholar, Trip, Medline, and Clinical Key) were searched to identify randomized clinical trials with patients exposed to azithromycin or clarithromycin in combination with a beta-lactam. All articles were critically reviewed for inclusion in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS Seven clinical trials were included. The treatment success rate for azithromycin-beta-lactam after 10 to 14 days was 87.55% and that for clarithromycin-beta-lactam after 5 to 7 days of therapy was 75.42%. Streptococcus pneumoniae was commonly found in macrolide groups, with 130 and 80 isolates in the clarithromycin-based and azithromycin-based groups, respectively. The length of hospital stay was an average of 8.45 days for patients receiving a beta-lactam-azithromycin combination and 7.25 days with a beta-lactam-clarithromycin combination. CONCLUSION Macrolide inter-class differences were noted, with a higher clinical success rate for azithromycin-based combinations. However, a shorter length of hospital stay was achieved with a clarithromycin-beta-lactam regimen. Thus, a macrolide combined with a beta-lactam should be chosen using susceptibility data from the treating facility.
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Affiliation(s)
- Jumana Al-Salloum
- College of Pharmacy, Gulf Medical University, Ajman, UAE
- Thumbay University Hospital, Ajman, UAE
| | | | - Rana Kamran Mahmood
- College of Pharmacy, Gulf Medical University, Ajman, UAE
- Response Plus Medical, Abu Dhabi, UAE
| | - Shabaz Mohiuddin Gulam
- College of Pharmacy, Gulf Medical University, Ajman, UAE
- Thumbay University Hospital, Ajman, UAE
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Glick HA, Miyazaki T, Hirano K, Gonzalez E, Jodar L, Gessner BD, Isturiz RE, Arguedas A, Kohno S, Suaya JA. One-Year Quality of Life Post-Pneumonia Diagnosis in Japanese Adults. Clin Infect Dis 2021; 73:283-290. [PMID: 32447366 PMCID: PMC8282327 DOI: 10.1093/cid/ciaa595] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 05/21/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Pneumonia is a common, serious illness in the elderly, with a poorly characterized long-term impact on health-related quality of life (HRQoL). The Japanese Goto Epidemiology Study is a prospective, active, population-based surveillance study of adults with X-ray/CT scan-confirmed community-onset pneumonia, assessing the HRQoL outcome quality-adjusted life-years (QALYs). We report QALY scores and losses among a subset of participants in this study. METHODS QALYs were derived from responses to the Japanese version of the EuroQol-5D-5L health-state classification instrument at days 0, 7, 15, 30, 90, 180, and 365 after pneumonia diagnosis from participants enrolled from June 2017 to May 2018. We used patients as their own controls, calculating comparison QALYs by extrapolating EuroQol-5D-5L scores for day -30, accounting for mortality and changes in scores with age. RESULTS Of 405 participants, 85% were aged ≥65 years, 58% were male, and 69% were hospitalized for clinically and radiologically confirmed pneumonia. Compliance with interviews by patients or proxies was 100%. Adjusted EuroQol-5D-5L scores were 0.759, 0.561, 0.702, and 0.689 at days -30, 0 (diagnosis), 180, and 365, respectively. Average scores at all time points remained below the average day -30 scores (P ≤ .001). Pneumonia resulted in a 1-year adjusted loss of 0.13 QALYs (~47.5 quality-adjusted days) (P < .001). CONCLUSIONS Substantial QALY losses were observed among Japanese adults following pneumonia diagnosis, and scores had not returned to prediagnosis levels at 1 year postdiagnosis. QALY scores and cumulative losses were comparable to those in US adults with chronic heart failure, stroke, or renal failure.
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Affiliation(s)
- Henry A Glick
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Taiga Miyazaki
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
- Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Katsuji Hirano
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Elisa Gonzalez
- Vaccines Medical Development and Scientific/Clinical Affairs, Pfizer Inc, Collegeville, Pennsylvania, USA
| | - Luis Jodar
- Vaccines Medical Development and Scientific/Clinical Affairs, Pfizer Inc, Collegeville, Pennsylvania, USA
| | - Bradford D Gessner
- Vaccines Medical Development and Scientific/Clinical Affairs, Pfizer Inc, Collegeville, Pennsylvania, USA
| | - Raul E Isturiz
- Vaccines Medical Development and Scientific/Clinical Affairs, Pfizer Inc, Collegeville, Pennsylvania, USA
| | - Adriano Arguedas
- Vaccines Medical Development and Scientific/Clinical Affairs, Pfizer Inc, Collegeville, Pennsylvania, USA
| | - Shigeru Kohno
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Jose A Suaya
- Vaccines Medical Development and Scientific/Clinical Affairs, Pfizer Inc, Collegeville, Pennsylvania, USA
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Lodise TP, Colman S, Alexander E, Stein DS, Fitts D, Goldberg L, Schranz J. Health-Related Quality of Life as Measured by the 12-Item Short-Form Survey Among Adults With Community-Acquired Bacterial Pneumonia who Received Either Lefamulin or Moxifloxacin in 2 Phase III Randomized, Double-Blind, Double-Dummy Clinical Trials. Open Forum Infect Dis 2020; 7:ofaa209. [PMID: 32617376 PMCID: PMC7314585 DOI: 10.1093/ofid/ofaa209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 05/29/2020] [Indexed: 01/27/2023] Open
Abstract
Background Interest in patient-reported outcomes (PROs) as part of benefit–risk assessment for new drug approvals is increasing. Lefamulin is the first intravenous (IV) and oral pleuromutilin antibiotic for treatment of adults with community-acquired bacterial pneumonia (CABP). Assessment of health-related quality of life (HRQoL) was prospectively incorporated in its CABP trials (Lefamulin Evaluation Against Pneumonia [LEAP] 1 and 2) via the 12-Item Short-Form Survey (SF-12), a widely used PRO that measures general health status in 8 domains. Methods HRQoL was evaluated by SF-12 at baseline and test of cure (TOC; 5–10 days after the last study drug dose) in patients who received lefamulin or moxifloxacin in LEAP 1 (IV/oral treatment) and LEAP 2 (oral-only treatment). SF-12 outcomes included the 8 domains, physical component and mental component summary scores, and the Short-Form Six-Dimension health utility score. Results Analysis included 1215 patients (lefamulin: n = 607; moxifloxacin: n = 608). At baseline, all mean SF-12 scores in both treatment groups were well below the United States reference mean. Clinically meaningful and significant improvements from baseline to TOC were observed in all SF-12 scores. No significant differences in mean score improvements from baseline to TOC between treatment groups were observed. SF-12 score improvements at TOC across predefined subgroups were comparable between treatment groups. Conclusions Results indicate that adults with CABP experienced comparable HRQoL improvements with lefamulin relative to moxifloxacin, and treatment with either agent resulted in returns to population norm HRQoL levels. These data suggest that lefamulin is a potential alternative to moxifloxacin for treatment of adults with CABP.
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Affiliation(s)
- Thomas P Lodise
- Albany College of Pharmacy and Health Sciences, Albany, New York, USA
| | - Sam Colman
- Covance Market Access Services Inc., Gaithersburg, Maryland, USA
| | | | - Daniel S Stein
- Nabriva Therapeutics US, Inc., King of Prussia, Pennsylvania, USA
| | - David Fitts
- Nabriva Therapeutics US, Inc., King of Prussia, Pennsylvania, USA
| | - Lisa Goldberg
- Nabriva Therapeutics US, Inc., King of Prussia, Pennsylvania, USA
| | - Jennifer Schranz
- Nabriva Therapeutics US, Inc., King of Prussia, Pennsylvania, USA
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Lloyd MA, Tang CY, Callander EJ, Janus ED, Karahalios A, Skinner EH, Lowe S, Karunajeewa HA. Patient-reported outcome measurement in community-acquired pneumonia: feasibility of routine application in an elderly hospitalized population. Pilot Feasibility Stud 2019; 5:97. [PMID: 31372236 PMCID: PMC6661077 DOI: 10.1186/s40814-019-0481-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 07/19/2019] [Indexed: 01/25/2023] Open
Abstract
Background Community-acquired pneumonia (CAP) is a leading cause of morbidity and mortality worldwide, but few studies have evaluated the feasibility of routine patient-reported outcome measures (PROMs) in this illness. This study investigates the feasibility and limitations of three credible PROM instruments in a representative hospitalized cohort to identify potential barriers to routine application. Methods A sample of multimorbid hospitalized subjects meeting a standardized CAP definition was recruited. Demographic and clinical data of those able and unable to participate in PROM assessment were compared. The EQ-5D-5L, CAP-Sym 18 Questionnaire, and Late-Life Function and Disability Instrument (LLFDI) were administered (via face-to-face interview) at admission and discharge and (via phone interview or mail) at 30 and 90 days post-discharge. Feasibility measures included the proportion of individuals able to participate in assessment, attrition rates, data completeness, and instrument completion times. Scores at admission and 30 days post-discharge were examined for association with age. Results Of 82 subjects screened, 44 (54%) participated. Cognitive impairment (n = 12, 15%) commonly precluded participation. Seventeen (39%) participants were lost to follow-up by 90 days. Missing data at item level was negligible for all instruments, regardless of the mode of completion. Completion of the three instruments collectively in a face-to-face interview took a median of 17 min (IQ range 13-21) per participant. The burden of reported symptoms at admission was higher for younger participants aged 18-74 years (mean (standard deviation)) CAP-Sym 18 score at admission 34.2 (18.6) vs. 19.0 (11.3) for those aged ≥ 75 years. Conclusions Routine application of PROMs can provide valuable information relating to multiple aspects of clinical recovery for individuals hospitalized with CAP. However, heterogeneous demographic characteristics and complex underlying health status introduce challenges to feasibility and interpretability of these instruments in this population. Trial registration ClinicalTrials.gov, NCT02835040.
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Affiliation(s)
- Melanie A Lloyd
- 1Department of Physiotherapy, Western Health, St Albans, Victoria 3021 Australia.,2Melbourne Medical School - Western Precinct, The University of Melbourne, St Albans, Victoria 3021 Australia
| | - Clarice Y Tang
- 1Department of Physiotherapy, Western Health, St Albans, Victoria 3021 Australia.,3Department of Physiotherapy, La Trobe University, Bundoora, Victoria 3000 Australia.,4Department of Physiotherapy, Western Sydney University, Penrith, New South Wales 2751 Australia
| | - Emily J Callander
- 5School of Medicine, Griffith University, Southport, Queensland 4215 Australia
| | - Edward D Janus
- 2Melbourne Medical School - Western Precinct, The University of Melbourne, St Albans, Victoria 3021 Australia.,6General Internal Medicine Unit, Western Health, Sunshine Hospital, St Albans, Victoria 3021 Australia
| | - Amalia Karahalios
- 7Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria 3010 Australia
| | - Elizabeth H Skinner
- 1Department of Physiotherapy, Western Health, St Albans, Victoria 3021 Australia.,8Department of Physiotherapy, Melbourne School of Health Sciences, University of Melbourne, Parkville, Victoria 3010 Australia.,9Department of Physiotherapy, School of Primary Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, Frankston, Victoria 3199 Australia
| | - Stephanie Lowe
- 1Department of Physiotherapy, Western Health, St Albans, Victoria 3021 Australia
| | - Harin A Karunajeewa
- 2Melbourne Medical School - Western Precinct, The University of Melbourne, St Albans, Victoria 3021 Australia.,6General Internal Medicine Unit, Western Health, Sunshine Hospital, St Albans, Victoria 3021 Australia.,10The Walter and Eliza Hall Institute of Medical Research, Parkville, 3052 Victoria Australia
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Cunha CB. Antibiotic Stewardship Program Perspective: Oral Antibiotic Therapy for Common Infectious Diseases. Med Clin North Am 2018; 102:947-954. [PMID: 30126583 DOI: 10.1016/j.mcna.2018.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Traditionally, initial antibiotic therapy was administered intravenously (IV). Over the past 3 decades, there has been increased understanding, appreciation, and application of pharmacokinetic (PK) and pharmacodynamic (PD) principles in antibiotic therapy. The utilization of PK/PD parameters as applied to antimicrobial therapy has led to optimizing dosage regimens as well as increased awareness and experience with oral versus antibiotic therapy. When an oral antibiotic, given at the same dose as its IV formulation, results in the same serum/tissue levels, then oral antibiotics should be used whenever possible. When chosen carefully, oral therapy provides many benefits over IV therapy.
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Affiliation(s)
- Cheston B Cunha
- Antibiotic Stewardship Program, Division of Infectious Disease, Rhode Island Hospital, 593 Eddy Street, Physicians Office Building, Suite #328, Providence, RI 02903, USA.
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9
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Daniel P, Bewick T, McKeever TM, Roberts M, Ashton D, Smith D, Latip L, Lim WS. Healthcare reconsultation in working-age adults following hospitalisation for community-acquired pneumonia. Clin Med (Lond) 2018; 18:41-46. [PMID: 29436438 PMCID: PMC6330906 DOI: 10.7861/clinmedicine.18-1-41] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Community-acquired pneumonia (CAP) is associated with prolonged symptom persistence during recovery. However, the effect of the residual symptom load on healthcare utilisation is unknown. The aim of this study was to quantify healthcare reconsultation within 28 days of hospital discharge for an index episode of CAP, and explore reasons for these reconsultations. Adults of working age admitted to any of four hospitals in the UK, with a primary diagnosis of CAP, were prospectively studied. Of 108 patients, 71 (65.7%) reconsulted healthcare services within 28 days of discharge; of these, 90.1% consulted their GP. Men were less likely to reconsult than women (adjusted odds ratio [aOR] 0.34, 95% confidence interval 0.13-0.91, p=0.032). Persistence of respiratory symptoms accounted for the majority of these reconsultations. Healthcare utilisation is high in working-age adults after an episode of hospitalised CAP and, in most cases, is due to failure to resolve index symptoms.
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Affiliation(s)
- Priya Daniel
- Department of Respiratory Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Thomas Bewick
- Derby Teaching Hospitals NHS Foundation Trust, Derby, UK
| | | | - Mark Roberts
- Department of Respiratory Medicine, King's Mill Hospital, Mansfield, UK
| | - Deborah Ashton
- Department of Respiratory Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Daniel Smith
- Derby Teaching Hospitals NHS Foundation Trust, Derby, UK
| | - Lenny Latip
- Derby Teaching Hospitals NHS Foundation Trust, Derby, UK
| | - Wei Shen Lim
- Department of Respiratory Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Wootton DG, Dickinson L, Pertinez H, Court J, Eneje O, Keogan L, Macfarlane L, Wilks S, Gallagher J, Woodhead M, Gordon SB, Diggle PJ. A longitudinal modelling study estimates acute symptoms of community acquired pneumonia recover to baseline by 10 days. Eur Respir J 2017; 49:49/6/1602170. [PMID: 28619956 PMCID: PMC5898948 DOI: 10.1183/13993003.02170-2016] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 02/22/2017] [Indexed: 12/14/2022]
Abstract
Our aims were to address three fundamental questions relating to the symptoms of community-acquired pneumonia (CAP): Do patients completely recover from pneumonia symptoms? How long does this recovery take? Which factors influence symptomatic recovery? We prospectively recruited patients at two hospitals in Liverpool, UK, into a longitudinal, observational cohort study and modelled symptom recovery from CAP. We excluded patients with cancer, immunosuppression or advanced dementia, and those who were intubated or palliated from admission. We derived a statistical model to describe symptom patterns. We recruited 169 (52% male) adults. Multivariable analysis demonstrated that the time taken to recover to baseline was determined by the initial severity of symptoms. Severity of symptoms was associated with comorbidity and was inversely related to age. The pattern of symptom recovery was exponential and most patients’ symptoms returned to baseline by 10 days. These results will inform the advice given to patients regarding the resolution of their symptoms. The recovery model described here will facilitate the use of symptom recovery as an outcome measure in future clinical trials. Severity of CAP symptoms is inversely related to age and resolution to baseline symptoms takes on average 10 dayshttp://ow.ly/dV0h30befE3
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Affiliation(s)
- Daniel G Wootton
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK .,Dept of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Laura Dickinson
- Dept of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Henry Pertinez
- Dept of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Joanne Court
- Dept of Respiratory Research, Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - Odiri Eneje
- Dept of Respiratory Research, Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - Lynne Keogan
- Dept of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Laura Macfarlane
- Dept of Respiratory Research, Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - Sarah Wilks
- Dept of Respiratory Research, Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | | | - Mark Woodhead
- Dept of Respiratory Medicine, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK.,Manchester Academic Health Science Centre and Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK
| | - Stephen B Gordon
- Dept of Respiratory Research, Aintree University Hospital NHS Foundation Trust, Liverpool, UK.,The Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Peter J Diggle
- CHICAS, Lancaster University Medical School, Lancaster University, Lancaster, UK
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Mangen MJJ, Huijts SM, Bonten MJM, de Wit GA. The impact of community-acquired pneumonia on the health-related quality-of-life in elderly. BMC Infect Dis 2017; 17:208. [PMID: 28292280 PMCID: PMC5351062 DOI: 10.1186/s12879-017-2302-3] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 03/01/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The sustained health-related quality-of-life of patients surviving community-acquired pneumonia has not been accurately quantified. The aim of the current study was to quantify differences in health-related quality-of-life of community-dwelling elderly with and without community-acquired pneumonia during a 12-month follow-up period. METHODS In a matched cohort study design, nested in a prospective randomized double-blind placebo-controlled trial on the efficacy of the 13-valent pneumococcal vaccine in community-dwelling persons of ≥65 years, health-related quality-of-life was assessed in 562 subjects hospitalized with suspected community-acquired pneumonia (i.e. diseased cohort) and 1145 unaffected persons (i.e. non-diseased cohort) matched to pneumonia cases on age, sex, and health status (EQ-5D-3L-index). Health-related quality-of-life was determined 1-2 weeks after hospital discharge/inclusion and 1, 6 and 12 months thereafter, using Euroqol EQ-5D-3L and Short Form-36 Health survey questionnaires. One-year quality-adjusted life years (QALY) were estimated for both diseased and non-diseased cohorts. Separate analyses were performed for pneumonia cases with and without radiologically confirmed community-acquired pneumonia. RESULTS The one-year excess QALY loss attributed to community-acquired pneumonia was 0.13. Mortality in the post-discharge follow-up year was 8.4% in community-acquired pneumonia patients and 1.2% in non-diseased persons (p < 0.001). During follow-up health-related quality-of-life was persistently lower in community-acquired pneumonia patients, compared to non-diseased persons, but differences in health-related quality-of-life between radiologically confirmed and non-confirmed community-acquired pneumonia cases were not statistically significant. CONCLUSIONS Community-acquired pneumonia was associated with a six-fold increased mortality and 16% lower quality-of-life in the post-discharge year among patients surviving hospitalization for community-acquired pneumonia, compared to non-diseased persons. TRIAL REGISTRATION ClinicalTrials.gov, NCT00812084 .
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Affiliation(s)
- Marie-Josée J Mangen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Susanne M Huijts
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.,Department Respiratory Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marc J M Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.,Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - G Ardine de Wit
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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Emmet O'Brien M, Restrepo MI, Martin-Loeches I. Update on the combination effect of macrolide antibiotics in community-acquired pneumonia. Respir Investig 2015; 53:201-209. [PMID: 26344609 DOI: 10.1016/j.resinv.2015.05.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 05/23/2015] [Accepted: 05/27/2015] [Indexed: 06/05/2023]
Abstract
Community-acquired pneumonia (CAP) is a leading cause of death from an infectious cause worldwide. Guideline-concordant antibiotic therapy initiated in a timely manner is associated with improved treatment responses and patient outcomes. In the post-antibiotic era, much of the morbidity and mortality of CAP is as a result of the interaction between bacterial virulence factors and host immune responses. In patients with severe CAP, or who are critically ill, there is a lot of emerging observational evidence demonstrating improved survival rates when treatment using combination therapy with a β-lactam and a macrolide is initiated, as compared to other antibiotic regimes without a macrolide. Macrolides in combination with a β-lactam antibiotic provide broader coverage for the atypical organisms implicated in CAP, and may contribute to antibacterial synergism. However, it has been postulated that the documented immunomodulatory effects of macrolides are the primary mechanism for improved patient outcomes through attenuation of bacterial virulence factors and host systemic inflammatory responses. Despite concerns regarding the limitations of observational evidence and the lack of confirmatory randomized controlled trials, the potential magnitude of mortality benefits estimated at 20-50% cannot be overlooked. In light of recent data from a number of trials showing that combination treatment with a macrolide and a suitable second agent is justified in all patients with severe CAP, such treatment should be obligatory for those admitted to an intensive care setting.
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Affiliation(s)
- M Emmet O'Brien
- Multidisciplinary Intensive Care Research Organization, Trinity Centre for Health Sciences, St. James's Hospital, Dublin 8, Ireland.
| | - Marcos I Restrepo
- South Texas Veterans Health Care System, Audie L. Murphy Memorial Veterans Hospital, Medicine, San Antonio, TX, USA.
| | - Ignacio Martin-Loeches
- Multidisciplinary Intensive Care Research Organization, Trinity Centre for Health Sciences, St. James's Hospital, Dublin 8, Ireland.
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Welte T. Managing CAP patients at risk of clinical failure. Respir Med 2015; 109:157-69. [DOI: 10.1016/j.rmed.2014.10.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 10/07/2014] [Accepted: 10/27/2014] [Indexed: 12/11/2022]
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Pakhale S, Mulpuru S, Verheij TJM, Kochen MM, Rohde GGU, Bjerre LM. Antibiotics for community-acquired pneumonia in adult outpatients. Cochrane Database Syst Rev 2014; 2014:CD002109. [PMID: 25300166 PMCID: PMC7078574 DOI: 10.1002/14651858.cd002109.pub4] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Lower respiratory tract infection (LRTI) is the third leading cause of death worldwide and the first leading cause of death in low-income countries. Community-acquired pneumonia (CAP) is a common condition that causes a significant disease burden for the community, particularly in children younger than five years, the elderly and immunocompromised people. Antibiotics are the standard treatment for CAP. However, increasing antibiotic use is associated with the development of bacterial resistance and side effects for the patient. Several studies have been published regarding optimal antibiotic treatment for CAP but many of these data address treatments in hospitalised patients. This is an update of our 2009 Cochrane Review and addresses antibiotic therapies for CAP in outpatient settings. OBJECTIVES To compare the efficacy and safety of different antibiotic treatments for CAP in participants older than 12 years treated in outpatient settings with respect to clinical, radiological and bacteriological outcomes. SEARCH METHODS We searched CENTRAL (2014, Issue 1), MEDLINE (January 1966 to March week 3, 2014), EMBASE (January 1974 to March 2014), CINAHL (2009 to March 2014), Web of Science (2009 to March 2014) and LILACS (2009 to March 2014). SELECTION CRITERIA We looked for randomised controlled trials (RCTs), fully published in peer-reviewed journals, of antibiotics versus placebo as well as antibiotics versus another antibiotic for the treatment of CAP in outpatient settings in participants older than 12 years of age. However, we did not find any studies of antibiotics versus placebo. Therefore, this review includes RCTs of one or more antibiotics, which report the diagnostic criteria and describe the clinical outcomes considered for inclusion in this review. DATA COLLECTION AND ANALYSIS Two review authors (LMB, TJMV) independently assessed study reports in the first publication. In the 2009 update, LMB performed study selection, which was checked by TJMV and MMK. In this 2014 update, two review authors (SP, SM) independently performed and checked study selection. We contacted trial authors to resolve any ambiguities in the study reports. We compiled and analysed the data. We resolved differences between review authors by discussion and consensus. MAIN RESULTS We included 11 RCTs in this review update (3352 participants older than 12 years with a diagnosis of CAP); 10 RCTs assessed nine antibiotic pairs (3321 participants) and one RCT assessed four antibiotics (31 participants) in people with CAP. The study quality was generally good, with some differences in the extent of the reporting. A variety of clinical, bacteriological and adverse events were reported. Overall, there was no significant difference in the efficacy of the various antibiotics. Studies evaluating clarithromycin and amoxicillin provided only descriptive data regarding the primary outcome. Though the majority of adverse events were similar between all antibiotics, nemonoxacin demonstrated higher gastrointestinal and nervous system adverse events when compared to levofloxacin, while cethromycin demonstrated significantly more nervous system side effects, especially dysgeusia, when compared to clarithromycin. Similarly, high-dose amoxicillin (1 g three times a day) was associated with higher incidence of gastritis and diarrhoea compared to clarithromycin, azithromycin and levofloxacin. AUTHORS' CONCLUSIONS Available evidence from recent RCTs is insufficient to make new evidence-based recommendations for the choice of antibiotic to be used for the treatment of CAP in outpatient settings. Pooling of study data was limited by the very low number of studies assessing the same antibiotic pairs. Individual study results do not reveal significant differences in efficacy between various antibiotics and antibiotic groups. However, two studies did find significantly more adverse events with use of cethromycin as compared to clarithromycin and nemonoxacin when compared to levofloxacin. Multi-drug comparisons using similar administration schedules are needed to provide the evidence necessary for practice recommendations. Further studies focusing on diagnosis, management, cost-effectiveness and misuse of antibiotics in CAP and LRTI are warranted in high-, middle- and low-income countries.
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Affiliation(s)
- Smita Pakhale
- The Ottawa Hospital, Ottawa Hospital Research Institute and the University of OttawaDepartment of Medicine501 Smyth RoadOttawaONCanadaK1H 8L6
| | - Sunita Mulpuru
- The Ottawa Hospital, General CampusDivision of Respirology501 Smyth RoadBox 211OttawaONCanadaK1H 8L6
| | - Theo JM Verheij
- University Medical Center UtrechtJulius Center for Health Sciences and Primary CarePO Box 85500UtrechtNetherlands3508 GA
| | - Michael M Kochen
- University of Göttingen Medical SchoolDepartment of General Practice/Family MedicineLudwigstrasse 37FreiburgGermanyD‐79104
| | - Gernot GU Rohde
- Maastricht University Medical CenterDepartment of Respiratory MedicinePO box 5800MaastrichtNetherlands6202 AZ
- CAPNETZ STIFTUNGHannoverGermany
| | - Lise M Bjerre
- University of OttawaDepartment of Family Medicine, Bruyere Research Institute43 Bruyere StRoom 369YOttawaONCanadaK1N 5C8
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Kuzman I, Bezlepko A, Kondova Topuzovska I, Rókusz L, Iudina L, Marschall HP, Petri T. Efficacy and safety of moxifloxacin in community acquired pneumonia: a prospective, multicenter, observational study (CAPRIVI). BMC Pulm Med 2014; 14:105. [PMID: 24975809 PMCID: PMC4105837 DOI: 10.1186/1471-2466-14-105] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Accepted: 06/18/2014] [Indexed: 01/12/2023] Open
Abstract
Background Community acquired pneumonia (CAP) is a major cause of morbidity, hospitalization, and mortality worldwide. Management of CAP for many patients requires rapid initiation of empirical antibiotic treatment, based on the spectrum of activity of available antimicrobial agents and evidence on local antibiotic resistance. Few data exist on the severity profile and treatment of hospitalized CAP patients in Eastern and Central Europe and the Middle East, in particular on use of moxifloxacin (Avelox®), which is approved in these regions. Methods CAPRIVI (Community Acquired Pneumonia: tReatment wIth AVelox® in hospItalized patients) was a prospective observational study in 12 countries: Croatia, France, Hungary, Kazakhstan, Jordan, Kyrgyzstan, Lebanon, Republic of Moldova, Romania, Russia, Ukraine, and Macedonia. Patients aged >18 years were treated with moxifloxacin 400 mg daily following hospitalization with a CAP diagnosis. In addition to efficacy and safety outcomes, data were collected on patient history and disease severity measured by CRB-65 score. Results 2733 patients were enrolled. A low severity index (i.e., CRB-65 score <2) was reported in 87.5% of CAP patients assessed (n = 1847), an unexpectedly high proportion for hospitalized patients. Moxifloxacin administered for a mean of 10.0 days (range: 2.0 to 39.0 days) was highly effective: 96.7% of patients in the efficacy population (n = 2152) improved and 93.2% were cured of infection during the study. Severity of infection changed from “moderate” or “severe” in 91.8% of patients at baseline to “no infection” or “mild” in 95.5% at last visit. In the safety population (n = 2595), 127 (4.9%) patients had treatment-emergent adverse events (TEAEs) and 40 (1.54%) patients had serious TEAEs; none of these 40 patients died. The safety results were consistent with the known profile of moxifloxacin. Conclusions The efficacy and safety profiles of moxifloxacin at the recommended dose of 400 mg daily are characterized in this large observational study of hospitalized CAP patients from Eastern and Central Europe and the Middle East. The high response rate in this study, which included patients with a range of disease severities, suggests that treatment with broader-spectrum drugs such as moxifloxacin is appropriate for patients with CAP who are managed in hospital. Trial registration ClinicalTrials.gov identifier: NCT00987792
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Affiliation(s)
- Ilija Kuzman
- University of Zagreb School of Medicine, University Hospital for Infectious Diseases "Dr, Fran Mihaljević", Mirogojska cesta 8, 10000 Zagreb, Croatia.
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Burkhardt O, Welte T. 10 years’ experience with the pneumococcal quinolone moxifloxacin. Expert Rev Anti Infect Ther 2014; 7:645-68. [DOI: 10.1586/eri.09.46] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Chilet-Rosell E, Ruiz-Cantero MT, Pardo MA. Gender analysis of moxifloxacin clinical trials. J Womens Health (Larchmt) 2013; 23:77-104. [PMID: 24180298 DOI: 10.1089/jwh.2012.4171] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
PURPOSE To determine the inclusion of women and the sex-stratification of results in moxifloxacin Clinical Trials (CTs), and to establish whether these CTs considered issues that specifically affect women, such as pregnancy and use of hormonal therapies. Previous publications about women's inclusion in CTs have not specifically studied therapeutic drugs. Although this type of drug is taken by men and women at a similar rate, adverse effects occur more frequently in the latter. METHODS We reviewed 158 published moxifloxacin trials on humans, retrieved from MedLine and the Cochrane Library (1998-2010), to determine whether they complied with the gender recommendations published by U.S. Food and Drug Administration Guideline. RESULTS Of a total of 80,417 subjects included in the moxifloxacin CTs, only 33.7% were women in phase I, in contrast to phase II, where women accounted for 45%, phase III, where they represented 38.3% and phase IV, where 51.3% were women. About 40.9% (n=52) of trials were stratified by sex and 15.3% (n=13) and 9% (n=7) provided data by sex on efficacy and adverse effects, respectively. We found little information about the influence of issues that specifically affect women. Only 3 of the 59 journals that published the moxifloxacin CTs stated that authors should stratify their results by sex. CONCLUSIONS Women are under-represented in the published moxifloxacin trials, and this trend is more marked in phase I, as they comprise a higher proportion in the other phases. Data by sex on efficacy and adverse effects are scarce in moxifloxacin trials. These facts, together with the lack of data on women-specific issues, suggest that the therapeutic drug moxifloxacin is only a partially evidence-based medicine.
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Yuan X, Liang BB, Wang R, Liu YN, Sun CG, Cai Y, Yu XH, Bai N, Zhao TM, Cui JC, Chen LA. Treatment of community-acquired pneumonia with moxifloxacin: a meta-analysis of randomized controlled trials. J Chemother 2013. [PMID: 23182045 DOI: 10.1179/1973947812y.0000000028] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Community-acquired pneumonia (CAP) is a leading cause of morbidity and mortality throughout the world. To investigate whether moxifloxacin monotherapy is associated with better clinical outcomes than other antibiotics recommended for CAP among adults with mild-to-moderate or severe CAP, we performed a meta-analysis. MEDLINE, EMBASE, Web of Science, and the Cochrane Library were searched for randomized control trials (RCTs). The efficacy and safety of moxifloxacin were compared with other antimicrobial agents used to treat CAP. Fourteen RCTs, consisting of 6923 total patients, were included in the meta-analysis. No difference was found regarding the incidence of adverse events and mortality between moxifloxacin and the compared regimens. We found that moxifloxacin is as effective and well-tolerated as other recommended antibiotics for the treatment of CAP and possesses a better pathogen eradication rate than beta-lactam-based therapy.
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Affiliation(s)
- Xin Yuan
- Department of Respiratory Diseases, General Hospital of Chinese People’s Liberation Army, Beijing, China
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Ruhe J, Mildvan D. Does Empirical Therapy with a Fluoroquinolone or the Combination of a β-Lactam Plus a Macrolide Result in Better Outcomes for Patients Admitted to the General Ward? Infect Dis Clin North Am 2013; 27:115-32. [DOI: 10.1016/j.idc.2012.11.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Berk V, Demiraslan H, Berk E, Karaca H, Inanc M, Bozkurt O, Ozkan M. Moxifloxacin-associated neutropenia. SCANDINAVIAN JOURNAL OF INFECTIOUS DISEASES 2012; 45:415-6. [PMID: 23151058 DOI: 10.3109/00365548.2012.738937] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
A 32-y-old woman presented with pneumonia. Treatment was started with moxifloxacin. On day 2 of moxifloxacin treatment the patient developed neutropenia. After discontinuing the moxifloxacin, neutrophil counts were normal on day 4. Clinicians should be aware of the possibility of this adverse effect in patients treated with moxifloxacin.
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Affiliation(s)
- Veli Berk
- Deparment of Medical Oncology, Erciyes University Medical School, Kayseri,Turkey.
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Barth J, Stauch K, Landen H. Efficacy and tolerability of sequential intravenous/oral moxifloxacin therapy in pneumonia: results of the first post-marketing surveillance study with intravenous moxifloxacin in hospital practice. Clin Drug Investig 2012; 25:691-700. [PMID: 17532715 DOI: 10.2165/00044011-200525110-00002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
OBJECTIVE This study aimed to investigate the efficacy, safety and tolerability of sequential intravenous (IV)/oral therapy with moxifloxacin in pneumonia under general hospital treatment conditions. PATIENTS AND METHODS Patients with pneumonia were documented in this non-interventional multicentre study. The patients were treated with IV moxifloxacin or moxifloxacin sequential therapy (IV and oral) in hospitals throughout Germany. Exclusion criteria were limited to the contraindications mentioned in the summary of product characteristics. The participating hospital-based physicians documented the patients' demography, anamnesis, antibiotic pretreatment, concomitant diseases and medications. Moxifloxacin therapy and symptom status were recorded daily up to the ninth day and on the last day of treatment. The physicians assessed the efficacy and tolerability of IV moxifloxacin therapy and reported all adverse events observed within the treatment period. RESULTS The 1749 documented patients had a mean age of 66.2 (SD 15.5) years; 56.4% were males and 43.5% females. The majority (99.3%) were treated with moxifloxacin 400mg once daily. On average, moxifloxacin was given for 7.6 days (SD 3.2). In cases of sequential therapy (78.9% of patients), IV moxifloxacin was switched to oral moxifloxacin after a mean of 4.1 days (SD 1.8). Moxifloxacin produced a significant clinical improvement in 58.2% of patients by day 3 of therapy, in 84.2% by day 5 and in 89.4% by day 7. Recovery occurred in 27.0% of patients by day 5, in 54.0% by day 7 and in 87.0% by day 14. It took a mean of 3.4 days (SD 1.9) until improvement and 7.2 days (SD 3.0) until cure. Overall efficacy of IV moxifloxacin therapy was rated by the physicians as 'very good' or 'good' in 82.9% of patients. Tolerability was rated in 94.3% of patients as 'very good' or 'good'. Adverse events were recorded for 92 (5.3%) patients, but events were considered by the attending physician to be related to moxifloxacin therapy for only 45 patients (2.6%). CONCLUSIONS IV moxifloxacin shows high efficacy in the treatment of pneumonia under routine clinical treatment conditions. IV moxifloxacin relieves pneumonia-associated symptoms rapidly and allows an early switch to oral administration. Because of its high efficacy and very good safety and tolerability profile, moxifloxacin delivers excellent benefits as first-line therapy for pneumonia.
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Affiliation(s)
- J Barth
- Berufsgenossenschaftliche Kliniken Bergmannstrost Halle, Halle/Saale, Germany
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Eliakim-Raz N, Robenshtok E, Shefet D, Gafter-Gvili A, Vidal L, Paul M, Leibovici L. Empiric antibiotic coverage of atypical pathogens for community-acquired pneumonia in hospitalized adults. Cochrane Database Syst Rev 2012; 2012:CD004418. [PMID: 22972070 PMCID: PMC7017099 DOI: 10.1002/14651858.cd004418.pub4] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Community-acquired pneumonia (CAP) is caused by various pathogens, traditionally divided into 'typical' and 'atypical'. Initial antibiotic treatment of CAP is usually empirical, customarily covering both typical and atypical pathogens. To date, no sufficient evidence exists to support this broad coverage, while limiting coverage is bound to reduce toxicity, resistance and expense. OBJECTIVES The main objective was to estimate the mortality and proportion with treatment failure using regimens containing atypical antibiotic coverage compared to those that had typical coverage only. Secondary objectives included the assessment of adverse events. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) Issue 3, 2012 which includes the Acute Respiratory Infection Group's Specialized Register, MEDLINE (January 1966 to April week 1, 2012) and EMBASE (January 1980 to April 2012). SELECTION CRITERIA Randomized controlled trials (RCTs) of adult patients hospitalized due to CAP, comparing antibiotic regimens with atypical coverage (quinolones, macrolides, tetracyclines, chloramphenicol, streptogramins or ketolides) to a regimen without atypical antibiotic coverage. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the risk of bias and extracted data from included trials. We estimated risk ratios (RRs) with 95% confidence intervals (CIs). We assessed heterogeneity using a Chi(2) test. MAIN RESULTS We included 28 trials, encompassing 5939 randomized patients. The atypical antibiotic was administered as monotherapy in all but three studies. Only one study assessed a beta-lactam combined with a macrolide compared to the same beta-lactam. There was no difference in mortality between the atypical arm and the non-atypical arm (RR 1.14; 95% CI 0.84 to 1.55), RR < 1 favors the atypical arm. The atypical arm showed an insignificant trend toward clinical success and a significant advantage to bacteriological eradication, which disappeared when evaluating methodologically high quality studies alone. Clinical success for the atypical arm was significantly higher for Legionella pneumophilae (L. pneumophilae) and non-significantly lower for pneumococcal pneumonia. There was no significant difference between the groups in the frequency of (total) adverse events, or those requiring discontinuation of treatment. However, gastrointestinal events were less common in the atypical arm (RR 0.70; 95% CI 0.53 to 0.92). Although the trials assessed different antibiotics, no significant heterogeneity was detected in the analyses. AUTHORS' CONCLUSIONS No benefit of survival or clinical efficacy was shown with empirical atypical coverage in hospitalized patients with CAP. This conclusion relates mostly to the comparison of quinolone monotherapy to beta-lactams. Further trials, comparing beta-lactam monotherapy to the same combined with a macrolide, should be performed.
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Affiliation(s)
- Noa Eliakim-Raz
- Department of Medicine E, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel.
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Are Fluoroquinolones Superior Antibiotics for the Treatment of Community-Acquired Pneumonia? Curr Infect Dis Rep 2012; 14:317-29. [DOI: 10.1007/s11908-012-0251-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Woodhead M, Blasi F, Ewig S, Garau J, Huchon G, Ieven M, Ortqvist A, Schaberg T, Torres A, van der Heijden G, Read R, Verheij TJM. Guidelines for the management of adult lower respiratory tract infections--summary. Clin Microbiol Infect 2012; 17 Suppl 6:1-24. [PMID: 21951384 DOI: 10.1111/j.1469-0691.2011.03602.x] [Citation(s) in RCA: 192] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
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.
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Affiliation(s)
- M Woodhead
- Department of Respiratory Medicine, Manchester Royal Infirmary, Oxford Road, Manchester, UK.
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Woodhead M, Blasi F, Ewig S, Garau J, Huchon G, Ieven M, Ortqvist A, Schaberg T, Torres A, van der Heijden G, Read R, Verheij TJM. Guidelines for the management of adult lower respiratory tract infections--full version. Clin Microbiol Infect 2011; 17 Suppl 6:E1-59. [PMID: 21951385 PMCID: PMC7128977 DOI: 10.1111/j.1469-0691.2011.03672.x] [Citation(s) in RCA: 585] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- M Woodhead
- Department of Respiratory Medicine, Manchester Royal Infirmary, Oxford Road, Manchester, UK.
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Wispelwey B, Schafer KR. Fluoroquinolones in the management of community-acquired pneumonia in primary care. Expert Rev Anti Infect Ther 2011; 8:1259-71. [PMID: 21073291 DOI: 10.1586/eri.10.110] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
A literature search was conducted to evaluate the pharmacokinetic and pharmacodynamic profile of the respiratory fluoroquinolones (gemifloxacin, levofloxacin and moxifloxacin) and their efficacy and safety in the management of community-acquired pneumonia (CAP). Data show that CAP is a common presentation in primary care practice, and is associated with high rates of morbidity and mortality, particularly in the elderly. Although the causative pathogens differ depending on treatment setting and patient factors, Streptococcus pneumoniae is the primary pathogen in all treatment settings. As a class, the respiratory fluoroquinolones have a very favorable pharmacokinetic and pharmacodynamic profile. Pharmacodynamic criteria suggest that moxifloxacin and gemifloxacin are more potent against S. pneumoniae, which may have the added benefit of reducing resistance selection and enhancing bacterial eradication. The respiratory fluoroquinolones are also generally well tolerated, and are first-line options for outpatient treatment of CAP in patients with comorbidities or previous antibiotic use.
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Affiliation(s)
- Brian Wispelwey
- Department of Medicine, Division of Infectious Diseases and International Health, University of Virginia Health Center, P.O. Box 801337, Charlottesville, VA 22908-1337, USA.
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Abstract
BACKGROUND Community-acquired pneumonia (CAP), the sixth most common cause of death worldwide, is a common condition representing a significant disease burden for the community, particularly in the elderly. Antibiotics are helpful in treating CAP and are the standard treatment. CAP contributes significantly to antibiotic use, which is associated with the development of bacterial resistance and side-effects. Several studies have been published concerning treatment for CAP. Available data arises mainly hospitalized patients studies. This is an update of our 2004 Cochrane Review. OBJECTIVES To summarize current evidence from randomized controlled trials (RCTs) concerning the efficacy of different antibiotic treatments for CAP in participants older than 12. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2009, issue 1) which contains the Cochrane Acute Respiratory Infections Group's Specialized Register; MEDLINE (January 1966 to February week 2, 2009), and EMBASE (January 1974 to February 2009). SELECTION CRITERIA RCTs in which one or more antibiotics were tested for the treatment of CAP in ambulatory adolescents or adults. Studies testing one or more antibiotics and reporting the diagnostic criteria as well as the clinical outcomes achieved, were considered for inclusion. DATA COLLECTION AND ANALYSIS Two review authors (LMB, TJMV) independently assessed study reports in the first publication. In this update, LMB performed study selection, which was checked by TJMV and MMK. Study authors were contacted to resolve any ambiguities in the study reports. Data were compiled and analyzed. Differences between review authors were resolved by discussion and consensus. MAIN RESULTS Six RCTs assessing five antibiotic pairs (1857 participants aged 12 years and older diagnosed with CAP) were included. The study quality was generally good, with some differences in the extent of the reporting. A variety of clinical, radiological and bacteriological diagnostic criteria and outcomes were reported. Overall, there was no significant difference in the efficacy of the various antibiotics. AUTHORS' CONCLUSIONS Currently available evidence from RCTs is insufficient to make evidence-based recommendations for the choice of antibiotic to be used for the treatment of CAP in ambulatory patients. Pooling of study data was limited by the very low number of studies assessing the same antibiotic pairs. Individual study results do not reveal significant differences in efficacy between various antibiotics and antibiotic groups. Multi-drug comparisons using similar administration schedules are needed to provide the evidence necessary for practice recommendations.
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Affiliation(s)
- Lise M Bjerre
- Department of General Practice/Family Medicine, University of Göttingen, Humboldtallee 38, Göttingen, Germany, D-37073
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Simoens S. Evidence for moxifloxacin in community-acquired pneumonia: the impact of pharmaco-economic considerations on guidelines. Curr Med Res Opin 2009; 25:2447-57. [PMID: 19678752 DOI: 10.1185/03007990903223663] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE In an era of limited resources, policy makers and health care payers are concerned about the costs of treatment in addition to its effectiveness. However, guidelines do not tend to consider the cost-effectiveness of treatment options. This paper aims to conduct an international literature review with a view to assessing the impact of pharmaco-economic considerations of CAP treatment with moxifloxacin on recent guidelines. METHODS The pharmaco-economic state of the art of treating CAP with moxifloxacin is assessed and compared with guidelines issued by the European Respiratory Society and by the Infectious Diseases Society of America/American Thoracic Society. Also, evidence on moxifloxacin consumption and antimicrobial resistance, and the impact of resistance on the cost-effectiveness of moxifloxacin is reviewed. Studies were identified by searching PubMed, Centre for Reviews and Dissemination databases, Cochrane Database of Systematic Reviews, and EconLit up to January 2009. RESULTS The existing pharmaco-economic evidence indicates that moxifloxacin is a cost-effective treatment for CAP. However, data limitations and uncertainty surrounding the evolution of resistance emphasize the need for caution. As recommended by guidelines, the choice of antimicrobial should consider the local frequency of causative pathogens, the local pattern of antimicrobial resistance, and risk factors for resistant bacteria. The pharmaco-economic evidence corroborates the importance of these factors as they have an impact on the cost-effectiveness of treating CAP patients with moxifloxacin. CONCLUSIONS CAP guidelines need to take into account pharmaco-economic considerations by balancing the effectiveness of antimicrobial regimens against their costs. The pharmaco-economic value of moxifloxacin is influenced by the causative pathogens involved and resistance patterns. Therefore, it may be advisable to identify patient subgroups in which treatment with moxifloxacin is cost-effective and should be recommended by guidelines.
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Affiliation(s)
- Steven Simoens
- Research Centre for Pharmaceutical Care and Pharmaco-economics, Faculty of Pharmaceutical Sciences, Katholieke Universiteit Leuven. Onderwijs en Navorsing 2, Herestraat 49, P.O. Box 521, 3000 Leuven, Belgium.
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Niven DJ, Laupland KB. Severe community-acquired pneumonia in adults: current antimicrobial chemotherapy. Expert Rev Anti Infect Ther 2009; 7:69-81. [DOI: 10.1586/14787210.7.1.69] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Gilbert DN. Clinical end points of therapy for patients with mild community-acquired pneumonia. Clin Infect Dis 2008; 47 Suppl 3:S140-4. [PMID: 18986280 DOI: 10.1086/591395] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Approximately 80% of patients with community-acquired pneumonia receive treatment as outpatients. The question is what are valid, reproducible, and quantifiable clinical end points that can be used in prospective clinical trials of the safety and efficacy of antibacterials. Patient-reported outcomes and measurements of time to end point are reasonable methods that, according to the limited data available, appear to work in clinical trials of therapy for mild-to-moderate community-acquired pneumonia among outpatients.
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Affiliation(s)
- David N Gilbert
- Department of Infectious Diseases, Providence Portland Medical Center, Portland, Oregon 97213, USA.
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File TM, Schentag JJ. What can we learn from the time course of untreated and partially treated community-onset Streptococcus pneumoniae pneumonia? A clinical perspective on superiority and noninferiority trial designs for mild community-acquired pneumonia. Clin Infect Dis 2008; 47 Suppl 3:S157-65. [PMID: 18986283 DOI: 10.1086/591398] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
There are no well-designed placebo-controlled clinical trials in the recent era that precisely define the magnitude of the drug effect of antimicrobial therapy for mild community-acquired pneumonia (CAP). However, there is evidence that ineffective therapies, selected on the basis of the ratio of 24-h area under the concentration curve to minimum inhibitory concentration, associated with a discordant (nonsusceptible in vitro) specific agent (or no therapy) for mild CAP due to Streptococcus pneumoniae are associated with increased risk of progression to serious CAP. The relatively high rate of clinical success associated with appropriate antimicrobial treatment of mild CAP renders a standard outcome measure of clinical success an unlikely way to differentiate new agents. However, there may be an advantage in composite outcome assessments for mild CAP. Composite-outcomes end points that include time to resolution of morbidity, the use of patient reported-outcomes instruments, and biomarkers are recommended for future studies. Because the composite rate of success in recent randomized clinical trials exceeds 90%, it would seem that a noninferiority margin of 10% is reasonable for trials for mild CAP.
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Affiliation(s)
- Thomas M File
- Northeastern Ohio Universities College of Medicine, Rootstown, Ohio, USA.
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Vardakas KZ, Siempos II, Grammatikos A, Athanassa Z, Korbila IP, Falagas ME. Respiratory fluoroquinolones for the treatment of community-acquired pneumonia: a meta-analysis of randomized controlled trials. CMAJ 2008; 179:1269-77. [PMID: 19047608 PMCID: PMC2585120 DOI: 10.1503/cmaj.080358] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND We investigated whether the use of respiratory fluoroquinolones was associated with better clinical outcomes compared with the use of macrolides and beta- lactams among adults with pneumonia. METHODS We searched PubMed, Current Contents, Scopus, EMBASE, ClinicalTrials.gov and Cochrane with no language restrictions. Two reviewers independently extracted data from published trials that compared fluoroquinolones (levofloxacin, moxifloxacin, gemifloxacin) with macrolides or beta-lactams or both. A meta-analysis was performed with the clinical outcomes of mortality, treatment success and adverse outcomes. RESULTS We included 23 trials in our meta-analysis. There was no difference in mortality among patients who received fluoroquinolones or the comparator antibiotics (OR 0.85, 95% CI 0.65-1.12). Pneumonia resolved in more patients who received fluoroquinolones compared with the comparator antibiotics for the included outcomes in the intention-to-treat population (OR 1.17, 95% CI 1.00-1.36), clinically evaluable population (OR 1.26, 95% CI 1.06-1.50) and the microbiologically assessed population (OR 1.67, 95% CI 1.28-2.20). Fluoroquinolones were more effective than a combination of beta-lactam and macrolide (OR 1.39, 95% CI 1.02-1.90). They were also more effective for patients with severe pneumonia (OR 1.84, 95% CI 1.02-3.29), those who required admission to hospital (OR = 1.30, 95% CI 1.04-1.61) and those who required intravenous therapy (OR = 1.44, 15% CI 1.13-1.85). Fluoroquinolones were more effective than beta-lactam and macrolide in open-label trials (OR = 1.35, 95% CI 1.08-1.69) but not in blinded randomized controlled trials (OR = 1.13, 95% CI 0.85-1.50). INTERPRETATION Fluoroquinolones were associated with higher success of treatment for severe forms of pneumonia; however, a benefit in mortality was not evident. A randomized controlled trial that includes patients with severe pneumonia with or without bacteremia is needed.
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Tillotson GS, Echols RM. Clinical trial design and consequences for drug development for community-acquired pneumonia: an industry perspective. Clin Infect Dis 2008; 47 Suppl 3:S237-40. [PMID: 18986296 DOI: 10.1086/591408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Antibiotic development has decreased significantly, in part because of recent changes in regulatory requirements in the United States. These changes both decrease the probability of technical and regulatory success for a new antibiotic for which marketing approval is sought and motivate the pharmaceutical industry to focus its research efforts on other therapeutic areas. There is a growing, unmet clinical need for new antibiotics, because of bacterial resistance to approved drugs; however, there are few candidates in development, especially new oral agents for treatment of community-acquired respiratory infections. The answers to important questions about the benefit of antibacterial treatment for community-acquired pneumonia and the publication of clear guidance for future clinical studies will support future investments. We discuss the underlying issues and offer some alternative strategies to enable improvements in clinical trial design for community-acquired pneumonia.
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Echols R, Tillotson G, Song J, Tosiello R. Clinical Trial Design for Mild‐to‐Moderate Community‐Acquired Pneumonia—An Industry Perspective. Clin Infect Dis 2008; 47 Suppl 3:S166-75. [DOI: 10.1086/591399] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Abstract
BACKGROUND Respiratory quinolones are a class of antimicrobials with a high activity against most respiratory pathogens. Moxifloxacin is a fourth-generation fluoroquinolone that has been shown to be effective against Gram-positive, Gram-negative, and atypical strains, as well as multi-drug resistant Streptococcus pneumoniae. OBJECTIVE To review and update the clinical efficacy of moxifloxacin in the treatment of respiratory infections. METHOD To perform a systematic review of publications on the clinical efficacy of moxifloxacin in respiratory infections. RESULTS The clinical efficacy of moxifloxacin has been shown in controlled studies of community-acquired pneumonia, exacerbations of chronic bronchitis and acute bacterial rhinosinusitis. Moxifloxacin has demonstrated a faster resolution of symptoms in community-acquired pneumonia and exacerbations of chronic bronchitis patients compared with first-line therapy together with excellent eradication rates. CONCLUSIONS The use of moxifloxacin as first-line therapy for moderate to severe respiratory infections in the community and the hospital has been recognized in international guidelines.
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Affiliation(s)
- Marc Miravitlles
- Servei de Pneumologia, Institut Clínic del Tòrax (IDIBAPS), Ciber de Enfermedades Respiratorias (CIBERES), Hospital Clínic, Barcelona, Spain.
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Ludlam HA, Enoch DA. Doxycycline or moxifloxacin for the management of community-acquired pneumonia in the UK? Int J Antimicrob Agents 2008; 32:101-5. [PMID: 18571380 DOI: 10.1016/j.ijantimicag.2008.02.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2008] [Accepted: 02/04/2008] [Indexed: 11/17/2022]
Abstract
Macrolide monotherapy is currently recommended as first-line treatment of mild-to-moderate community-acquired pneumonia (CAP) in penicillin-intolerant/allergic individuals in the UK. However, resistance rates among the commonest cause, Streptococcus pneumoniae, now exceed 10% in the UK and a review of alternative agents is therefore timely. This review considers the relative merits of two agents, doxycycline and moxifloxacin, which are candidates to replace macrolides for second-line therapy of non-severe CAP.
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Affiliation(s)
- H A Ludlam
- Clinical Microbiology & Public Health Laboratory, Box 236, Addenbrooke's Hospital, Cambridge University NHS Foundation Trust, Hills Road, Cambridge, UK
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40
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Xu S, Xiong S, Xu Y, Liu J, Liu H, Zhao J, Xiong W. Efficacy and safety of intravenous moxifloxacin versus cefoperazone with azithromycin in the treatment of community acquired pneumonia. ACTA ACUST UNITED AC 2008; 26:421-4. [PMID: 17120738 DOI: 10.1007/s11596-006-0411-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
To compare the efficacy, safety, and tolerability of intravenous moxifloxacin with those of a commonly used empirical antibiotic regimen, cefoperazone and azithromycin in the treatment of community acquired pneumonia (CAP) in adult patients requiring initial parenteral therapy, 40 patients with CAP were divided into two groups, a moxifloxacin group (n = 20) and a control group (n = 20), which were treated for 7 to 14 days. The patients in the moxifloxacin group were intravenously given 400 mg of moxifloxacin (Avelox) once a day. Patients in the control group were administered 2.0 g of cefoperazone twice a day and azithromycin 0.5 g once a day. Clinical, bacteriological, and laboratory examinations were performed before the treatment, and at the end of the treatment. Our results showed that there was no significant difference in the clinical efficacy rate between two treatment groups at end of therapy (90% for moxifloxacin, 95% for cefoperazone plus azithromycin) (P > 0.05). The bacteriologic eradication rate at the end of treatment was 90% in the moxifloxacin group and 80% in the cefoperazone-plus-azithromycin group, whereas there was no significant difference between the two groups (P > 0.05). In addition, both drugs were well-tolerated in this trial, with the number of drug-related adverse events being comparable. It is concluded that moxifloxacin is an effective and well-tolerated treatment for CAP and was equivalent to the commonly used empirical treatment of cefoperazone plus azithromycin. Moxifloxacin is likely to offer clinicians an alternative for reliable empirical CAP treatment in the face of increasing antibiotic resistance.
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Affiliation(s)
- Shuyun Xu
- Department of Respiratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
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Torres A, Garau J, Arvis P, Carlet J, Choudhri S, Kureishi A, Le Berre M, Lode H, Winter J, Read R. Moxifloxacin Monotherapy Is Effective in Hospitalized Patients with Community‐Acquired Pneumonia: The MOTIV Study—A Randomized Clinical Trial. Clin Infect Dis 2008; 46:1499-509. [DOI: 10.1086/587519] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Daneman N, Low D, McGeer A, Green K, Fisman D. At the Threshold: Defining Clinically Meaningful Resistance Thresholds for Antibiotic Choice in Community‐Acquired Pneumonia. Clin Infect Dis 2008; 46:1131-8. [DOI: 10.1086/529440] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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Martin M, Moore L, Quilici S, Decramer M, Simoens S. A cost-effectiveness analysis of antimicrobial treatment of community-acquired pneumonia taking into account resistance in Belgium. Curr Med Res Opin 2008; 24:737-51. [PMID: 18230196 DOI: 10.1185/030079908x273336] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE This article assesses the cost-effectiveness of outpatient antimicrobial treatment of community-acquired pneumonia (CAP) taking into account resistance in Belgium. RESEARCH DESIGN AND METHODS Our decision analytic model focused on mild to moderate CAP, but did not consider severe CAP. Treatment pathways reflected empirical treatment initiated in the absence of data on CAP aetiology. First-line treatment consisted of moxifloxacin, co-amoxiclav, cefuroxime or clarithromycin. If first-line treatment was unsuccessful, patients were either hospitalised or second-line treatment with a different antimicrobial was initiated. Clinical failure rates were obtained from the published literature or expert opinion. Costs were calculated using published sources from the third-party payer perspective. MAIN OUTCOME MEASURES Effectiveness measures included first-line clinical failure avoided, second-line treatment avoided, hospitalisation avoided and death avoided. Healthcare costs were included, but costs of productivity loss were not considered. RESULTS Costs of treating a CAP episode amounted to 144E with moxifloxacin/co-amoxiclav; 222E with co-amoxiclav/clarithromycin; 211E with cefuroxime/moxifloxacin; and 193E with clarithromycin/moxifloxacin. The rate of first-line failure was 5%, 16%, 19% and 18% for these four treatment strategies, respectively. The rate of second-line treatment amounted to 4%, 13%, 16% and 15%, respectively. The hospitalisation rate was 1%, 4%, 4% and 4%, respectively. The death rate was 0.01%, 0.04%, 0.03% and 0.03%, respectively. Sensitivity analyses supported the dominance of moxifloxacin/co-amoxiclav in nearly all scenarios. CONCLUSIONS First-line treatment of CAP patients with moxifloxacin followed by co-amoxiclav or hospitalisation if required was more effective and less costly as compared with first-line treatment with co-amoxiclav, cefuroxime or clarithromycin.
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Sabes-Figuera R, Segú JL, Puig-Junoy J, Torres A. Influence of bacterial resistances on the efficiency of antibiotic treatments for community-acquired pneumonia. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2008; 9:23-32. [PMID: 17221181 DOI: 10.1007/s10198-006-0019-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2006] [Accepted: 07/18/2006] [Indexed: 05/13/2023]
Abstract
The objective of this paper is to perform a cost-effectiveness analysis of the oral antibiotics used in Spain for the ambulatory treatment of community-acquired pneumonia. Our analysis takes into account the influence of bacterial resistances on the cost-effectiveness ratio of antibiotic alternatives from the viewpoint of the public insurer. A deterministic decision analysis model is used to simulate the impact of treatment alternatives on both patients' health and resource consumption. Amoxicillin 1 g may be the most efficient therapy for treating typical pneumonia, as long as the physician is able to discriminate clinically the aetiology of the process with a high degree of reliability. However, for those pathological pictures in which the aetiology cannot be discriminated clinically, and for those in which the consequences of incorrect diagnosis are serious according to clinical criteria, moxifloxacin is the most effective and efficient option.
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Robenshtok E, Shefet D, Gafter-Gvili A, Paul M, Vidal L, Leibovici L. Empiric antibiotic coverage of atypical pathogens for community acquired pneumonia in hospitalized adults. Cochrane Database Syst Rev 2008:CD004418. [PMID: 18254049 DOI: 10.1002/14651858.cd004418.pub3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Community acquired pneumonia (CAP) is caused by various pathogens, traditionally divided to 'typical' and 'atypical'. Initial antibiotic treatment of CAP is usually empirical, customarily covering both typical and atypical pathogens. To date, no sufficient evidence exists to support this broad coverage, while limiting coverage is bound to reduce toxicity, resistance and expense. OBJECTIVES To assess the efficacy and need of adding antibiotic coverage for atypical pathogens in hospitalized patients with CAP, in terms of mortality and successful treatment. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 1) which includes the Acute Respiratory Infection Group's specialized register; MEDLINE (January 1966 to March 2007); and EMBASE (January 1980 to January 2007). SELECTION CRITERIA Randomized trials of adult patients hospitalized due to CAP, comparing antibiotic regimens with atypical antibiotic coverage to a regimen without atypical antibiotic coverage. DATA COLLECTION AND ANALYSIS Two review authors independently appraised the quality of each trial and extracted the data from included trials. Relative risks (RR) with 95% confidence intervals (CI) were estimated, assuming an intention-to-treat (ITT) basis for the outcome measures. MAIN RESULTS Twenty five trials were included, encompassing 5244 randomized patients. There was no difference in mortality between the atypical arm and the non-atypical arm (RR 1.15; 95% CI 0.85 to 1.56). The atypical arm showed an insignificant trend toward clinical success and a significant advantage to bacteriological eradication, which disappeared when evaluating methodologically high-quality studies alone. Clinical success for the atypical arm was significantly higher for Legionella pneumophilae (L. pneumophilae) and non-significantly lower for pneumococcal pneumonia. There was no significant difference between the groups in the frequency of (total) adverse events, or those requiring discontinuation of treatment. However, gastrointestinal events were more common in the non-atypical arm (RR 0.73, 95% CI 0.54 to 0.99). All but two included trials compared a single atypical antibiotic to a beta-lactam, while no trials assessing the addition of an atypical antibiotic to a beta-lactam were identified. AUTHORS' CONCLUSIONS No benefit of survival or clinical efficacy was shown to empirical atypical coverage in hospitalized patients with CAP. This conclusion relates mostly to the comparison of quinolone monotherapy to beta-lactams (BL) or cephalosporins. Further trials, comparing BL or cephalosporins therapy to BL or cephalosporins combined with a macrolide in this population, using mortality as its primary outcome, should be performed.
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Affiliation(s)
- E Robenshtok
- Campus Beilinson, Dept of Medicine E, Rabin Medical Center, Petah-Tikva, Israel, 49100.
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Martin M, Quilici S, File T, Garau J, Kureishi A, Kubin M. Cost-effectiveness of empirical prescribing of antimicrobials in community-acquired pneumonia in three countries in the presence of resistance. J Antimicrob Chemother 2007; 59:977-89. [PMID: 17395688 DOI: 10.1093/jac/dkm033] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES To assess the cost-effectiveness of empirical outpatient treatment options for community-acquired pneumonia (CAP) in France, the USA and Germany, representing high, moderate and low antimicrobial resistance prevalence, respectively. METHODS A decision analytic model was developed for mild-to-moderate CAP outpatient treatment. Treatment algorithms incorporated follow-up after treatment failure due to resistance or other reasons. First-line treatment included moxifloxacin, beta-lactams, macrolides or doxycycline; second-line treatment used a different antimicrobial class. Country-specific resistance and co-resistance prevalences to first- and second-line therapy for the major CAP pathogens were derived from surveillance studies. Clinical failure rates due to antimicrobial-susceptible and -resistant pathogens were obtained from the literature or estimated. Total costs were estimated using standard sources and a third-party payer perspective. Outcome measures included first-line clinical failures avoided, second-line treatments avoided and hospitalizations avoided. Incremental cost-effectiveness ratios (ICERs) were calculated. RESULTS First-line moxifloxacin treatment followed by co-amoxiclav dominated all other treatments in France, the USA and in Germany for all outcome measures. Sensitivity analyses maintained moxifloxacin dominance in France and the USA but affected ICERs in some cases in Germany. CONCLUSIONS Antimicrobial resistance/spectrum have a significant impact on outcomes and costs in empirical outpatient CAP treatment. Despite low acquisition costs for generic antibiotics, first-line treatment effective against the major CAP pathogens, including strains resistant to other antimicrobials, resulted in better clinical outcomes in all countries and lower treatment costs for all.
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Affiliation(s)
- Monique Martin
- i3 Innovus, Beaufort House, Cricket Field Road, Uxbridge UB8 1QG, UK.
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47
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Denes E. [Antibiotherapy for acute CAP in adults]. Med Mal Infect 2006; 36:718-33. [PMID: 17092678 DOI: 10.1016/j.medmal.2006.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2006] [Accepted: 07/21/2006] [Indexed: 11/16/2022]
Abstract
Community acquired pneumonia is one of the most frequent infections. With time, bacterial epidemiology and bacterial resistance evolve and new antibiotics become available. So an up-date on adequate antibiotic use is necessary. We reviewed the epidemiology of pneumonia and the evolution of bacterial resistance. We also collected data on new antibiotics which can be used for this infection such as levofloxacin, moxifloxacin, telithromycin, and pristinamycin. All these drugs are effective on bacteria involved in pneumonia. At this time, only few Streptococcus pneumoniae strains have developed resistance to these drugs. However, resistance to fluoroquinolones is not easily detected with common laboratory techniques. There is no effectiveness difference between the 2 new fluoroquinolones (levofloxacin, moxifloxacin) in clinical studies. However, in bacteriological and pharmacological studies, moxifloxacin seems to be more effective than levofloxacin (500 mg/day). For the treatment of pneumonia due to Legionella pneumophila, fluoroquinolones are now widely recommended. For Streptococcus pneumonia, amoxicillin remain the drug of choice, even for bacteria with a decreased susceptibility to penicillin. The importance of treating atypical pathogens remains to be documented.
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Affiliation(s)
- E Denes
- Service de maladies infectieuses et tropicales, CHU Dupuytren, 2, avenue Martin-Luther-King, 87042 Limoges cedex, France.
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Abstract
Traditionally, antibiotics have been administered intravenously (IV) for serious systemic infections. As more potent oral antibiotics were introduced, and their pharmacokinetic aspects studied, orally administered antibiotics have been increasingly used for serious systemic infections. Antibiotics ideal for oral administration are those that have the appropriate spectrum, high degree of activity against the presumed or known pathogen, and have good bioavailability. Oral antibiotics with high bioavailability, that is > or = 90% absorbed, achieve serum/tissue concentrations comparable to IV administered antibiotics at the same dose. The popularity of "IV to PO switch therapy" is possible because of the availability of many potent oral antibiotics with high bioavailability. Initial IV therapy is appropriate in patients who are in shock/have impaired intestinal absorption, but after clinical defervescence, completion of therapy should be accomplished with oral antibiotics. As experience with "IV to PO switch therapy" has accumulated, confidence in oral antimicrobics for therapy of serious systemic infections has continued to increase. The trend in treating serious systemic infections entirely with oral antimicrobial therapy will continue, and is clearly the wave of the future.
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Affiliation(s)
- Burke A Cunha
- Infectious Disease Division, Winthrop-University Hospital, Mineola, NY 11501, USA
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Chidiac C. Pneumonies aiguës communautaires : analyse critique des essais cliniques. Med Mal Infect 2006; 36:650-66. [PMID: 16876363 DOI: 10.1016/j.medmal.2006.05.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2006] [Accepted: 05/19/2006] [Indexed: 11/21/2022]
Abstract
Optimal antibiotic treatment of community-acquired pneumonia (CAP) remains controversial. The clinical impact of S. pneumoniae resistance to macrolides is well documented. By contrast high dosage amoxicillin (1 g tid) remains active against such strains and no failure has been reported. The aim of this paper was to review clinical trials in community-acquired pneumonia, published from January 1, 1999, to December 31, 2005. One hundred seventy-three articles were collected, using Medline, 35 of which were analyzed, and 16 finally used. Telithromycin and pristinamycin may be used in mild to moderate CAP. Anti-pneumococcal fluoroquinolones such as levofloxacin and moxifloxacin may be used in at risk patients, but levofloxacin has only been investigated in patients with severe CAP and patients with Legionnaire's disease. Amoxicillin 1 g tid remains the drug of choice for pneumococcal CAP.
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Affiliation(s)
- C Chidiac
- Service des maladies infectieuses et tropicales et Inserm EA230, hôpital de la Croix-Rousse, 103, grande rue de la Croix-Rousse, 69317 Lyon, France.
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Niederman MS. Challenges in the management of community-acquired pneumonia: the role of quinolones and moxifloxacin. Clin Infect Dis 2006; 41 Suppl 2:S158-66. [PMID: 15942882 DOI: 10.1086/428056] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Current strategies and guidelines for the treatment of community-acquired pneumonia are directed toward making care cost effective, by treating patients on an outpatient basis whenever possible. The use of the new fluoroquinolones could help to achieve these goals. These agents are highly bioavailable and can facilitate the oral treatment of certain patients who otherwise might be admitted to the hospital, as outpatients. The good absorption and bioavailability of these agents can allow moderately ill patients to rapidly achieve effective serum levels of the drug after oral administration and can also facilitate early discontinuation of intravenous therapy and early discharge for responding inpatients. For inpatients or outpatients with clinical risk factors for acquiring drug-resistant pneumococci, quinolones represent a reliable monotherapy option and an effective alternative to a beta-lactam/macrolide combination. Although the in vitro differences among the various quinolones remain of unclear clinical relevance, preliminary data suggest that agents with enhanced in vitro activity against pneumococci, such as moxifloxacin, may have greater clinical efficacy and may lead to more-rapid resolution of fever and, potentially, less selection of future pneumococcal resistance to quinolones than that associated with agents with less intrinsic activity.
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Affiliation(s)
- Michael S Niederman
- Department of Medicine, State University of New York at Stony Brook, New York, USA.
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