Treating Community-acquired Bacterial Respiratory Tract Infections: Update on Etiology, Diagnosis, and Antimicrobial Therapy

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Treating Community-acquired Bacterial Respiratory Tract Infections: Update on Etiology, Diagnosis, and Antimicrobial Therapy

J Fam Pract. 2005 April;54(4):357-364

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References

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Antibiotics currently prescribed for patients with community-acquired bacterialRTIs

Empiric antibiotic therapy for patients with community-acquired bacterial RTIs should provide coverage against clinically important pathogens likely to be associated with these infections, including resistant strains (TABLE 3). The antibiotic selected should specifically target respiratory pathogens. For example, broad-spectrum antibiotics are not the optimum choice, as they affect both respiratory and nonrespiratory pathogens (eg, gram-negative enterics; Escherichia coliand Klebsiella pneumoniae), which may result in resistance among these organisms.^1,31

Antibiotics suitable for treatment of patients with ABS are summarized inTABLE 4. These agents vary widely in their spectra of activity as well as their ability to overcome pathogen resistance (TABLE 3). Amoxicillin, a very narrow-spectrum -lactam, generally is considered to be first-line therapy for children and adults who have ABS³² but may have little activity against resistant strains of S pneumoniae, H influenzae, and M catarrhalis.²

An analysis by the Agency for Healthcare Research and Quality concluded that amoxicillin or folate inhibitors (eg, TMP/SMX) are the most cost-effective choices for initial therapy in an otherwise healthy adult population with uncomplicated ABS.³³ For adults who fail to improve after 2 to 3 days, broad-spectrum and β-lactamase-resistant antibiotics for 7 to 14 days should be considered. A clinical practice guideline sponsored by the American Academy of Family Physicians, the American College of Physicians-Society of Internal Medicine, the CDC, and the IDSA recommends initiating treatment with narrow-spectrum agents, eg, amoxicillin, doxycycline, or TMP-SMX for patients with severe or persistent moderate symptoms of ABS.^34,35

High-dose amoxicillin/clavulanate 2000/125 mg, twice daily, was shown to be effective in treating patients with ABS, ABECB, and CAP caused by S pneumoniae, including penicillin-resistant S pneumoniae.²⁹

The macrolides erythromycin, clarithromycin, and azithromycin are effective against susceptible strains of all organisms commonly associated with ABS, but many strains of S pneumoniaealso are resistant to these drugs.^23,26 Respiratory fluoroquinolones are effective against all pathogens commonly associated with ABS, including resistant strains;²⁶ however, they also have significant activity against gram-negative enterobacteriaceae and thus may increase the potential for emergence of resistant strains of these organisms.³⁶ Ketolides are derived from the macrolide class and were designed to be effective against macrolide-resistant, gram-positive cocci.¹⁰ The first ketolide, telithromycin, is an alternative to macrolides for the treatment of patients with ABS, ABECB, and CAP. It is highly active against both common and atypical respiratory pathogens, including resistant strains, but has little activity against either enterobacteriaceae or anaerobes.³⁷

All of the same considerations mentioned for the treatment of ABS also apply to the selection of therapy for patients with ABECB or CAP (TABLE 4). Empiric antimicrobial therapy for these 2 conditions, particularly CAP, also must cover atypical respiratory pathogens.^17,38 For a number of years, monotherapy with a macrolide provided coverage against all of the pathogens likely to be associated with CAP and ABECB. In light of the emergence of resistance to these drugs by S pneumoniae, physicians should consider local and regional resistance rates before prescribing. In fact, File and colleagues³⁹ have suggested that current recommendations favoring the use of macrolides in patients with CAP may have to be reconsidered if clinical failure continues to be observed with these agents. Cunha³⁸ has taken an even stronger position, stating that macrolide monotherapy should be avoided in patients with CAP because of the high prevalence of S pneumoni-aeresistance to this class of antibiotics. These authors’ conclusions should be carefully weighed against the CDC’s and IDSA’s recommendations. The CDC previously recommended combination of macrolides and ceftriaxone for hospitalized patients to avoid emergence of fluoroquinolone resistance. The IDSA recommended empiric use of fluoroquinolones with conversion based on culture sensitivities when available.

TABLE 4

Antibiotics currently being used for the treatment of community-acquired bacterial respiratory tract infections^41-44

Generic	ABS*	CAP†	ABECB‡
β-Lactams
Amoxicillin	500 mg every 8 hours	500 mg to 1 g every 8 hours	500 mg 3 times daily
Amoxicillin/clavulanate	500 mg every 8 hours	500 mg/125 mg every 8 hours or 875 mg/125 mg every 12 hours	875/125 mg bid
Cefuroxime	250 to 500 mg twice daily	500 mg twice daily	500 mg twice daily
Macrolides
Clarithromycin	500 mg every 12 hours for 14 days	250–500 mg every 12 hours	500 or 750 mg every 12 hours for 7 to 14 days
Clarithromycin extended- release tablets	1000 mg once daily for 14 days	1000 mg once daily for 7 days	1000 mg once daily for 7 days
Azithromycin	500 mg once daily for 3 days	500 mg first day, then 250 mg/day for 2 to 5 days	500 mg once daily for 3 days or 500 mg first day, then 250 mg/day for 4 days
Erythromycin		250 to 500 mg twice daily	250 or 500 mg 3 or 4 times daily
Fluoroquinolone
Moxifloxacin	400 mg once daily for 10 days	400 mg once daily for 7 to 14 days	400 mg once daily for 5 days
Ketolide
Telithromycin	800 mg once daily for 5 days	800 mg once daily for 7 to 10 days	800 mg once daily for 5 days
Other Antibiotics
Trimethoprim- Sulfamethoxazole			160 mg trimethoprim and 800 mg sulfamethoxale every 12 hours for 14 days
*Treatment is for 10 to 14 days unless otherwise indicated.
†Treatment ranges from 7 to 14 days unless otherwise noted.
‡Treatment is for 10 days unless otherwise noted.