Fluoroquinolones in the Management of Community-acquired Pneumonia in Primary Care

Brian Wispelwey; Katherine R Schafer

Disclosures

Expert Rev Anti Infect Ther. 2010;8(11):1259-1271. 

In This Article

Treatment Guidelines for CAP

Recognizing that the majority of patients are treated by PCPs, hospitalists and emergency medicine specialists, committees of IDSA and ATS have formulated guidelines to assist these professionals in making clinical decisions and developing treatment strategies that will result in better patient outcomes.[1] Table 2 presents the guideline-recommended empirical antibiotic therapy for patients with CAP in three populations. Outpatient treatment in patients with no cardiopulmonary disease and/or other modifying factors may be treated with a macrolide or doxycycline. In these patients, monotherapy is appropriate and there is no indication for dual therapy.[1] In those with cardiopulmonary disease and/or other modifying factors, recommended treatment is a respiratory fluoroquinolone, such as moxifloxacin, levofloxacin or gemifloxacin, or a β-lactam plus a macrolide.[1]

Hospitalized patients not in the ICU can be treated with a respiratory fluoroquinolone or a combination of β-lactam plus a macrolide. A respiratory fluoroquinolone is preferred in patients with penicillin allergies.[1] In patients requiring ICU treatment but not at risk for Pseudomonas aeruginosa, a β-lactam plus either a respiratory fluoroquinolone or azithromycin should be given. In patients with penicillin allergies, a respiratory fluoroquinolone and aztreonam are recommended. ICU patients with CAP who are at risk for P. aeruginosa should receive an antipneumococcal, antipseudomonal β-lactam plus either ciprofloxacin or levofloxacin. Alternatively, treatment may include the above β-lactam plus an aminoglycoside and azithromycin, or the above β-lactam plus an aminoglycoside and an antipneumococcal fluoroquinolone. Aztreonam may be substituted for the β-lactam in patients with penicillin allergies.[1] Because monotherapy with a respiratory fluoroquinolone has not been established for severe CAP, patients admitted to the ICU should receive fluoroquinolones in combination with a β-lactam. Evidence suggests that combination therapy is associated with lower mortality than monotherapy in patients with bacteremic pneumococcal pneumonia.[1]

Antibiotic treatment should be initiated as soon as a diagnosis is established. Although previous IDSA guidelines recommended that patients receive their initial antibiotics 4 h or less after hospital admission,[15,37] a recent report by Baum and Kaltsas indicates that reduction of initiation time from 8 h or less to 4 h or less raises the potential for emerging drug resistance in pathogens commonly found in patients with CAP.[38] Rapid initiation of antibiotic therapy without sufficient proof that the patient is suffering from pneumonia rather than a viral respiratory infection can result in unnecessary use of these agents, and may increase the incidence of Clostridium difficile colitis, which places patients at greater risk for morbidity and mortality.[38] Thus, the timing of treatment initiation must be carried out in the context of an accurate diagnosis. Although current IDSA/ATS recommendations do not specify a window within which antibiotic therapy must be initiated, they do suggest that a delay in antibiotic therapy has adverse consequences in many cases.[1]

Treatment duration is another important consideration. Patients with CAP should be treated with antibiotics for a minimum of 5 days, and they should be afebrile for 48–72 h and have no more than one CAP-associated sign of clinical instability prior to discontinuation. Longer duration of therapy may be necessary if the initial antibiotic was not active against the causative pathogen or if there were extrapulmonary infectious complications.[1] Patients who have been hospitalized and are receiving intravenous antibiotics should be switched to oral therapy as soon as they are hemodynamically stable, improving clinically, able to ingest medications, and have normal digestion.[1]

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