Antimicrobial treatment of lower respiratory tract infections in the hospital setting

Biochemical Characterization of New Gemifloxacin Schiff Base (GMFX-o-phdn) Metal Complexes and Evaluation of Their Antimicrobial Activity against Some Phyto- or Human Pathogens

Four novel ligand-metal complexes were synthesized through the reaction of Fe(III), pleaseCo(II), Zn(II), and Zr(IV) with Schiff base gemifloxacin reacted with ortho-phenylenediamine (GMFX-o-phdn) to investigate their biological activities. Elemental analysis, FT-IR, 1H NMR, UV-visible, molar conductance, melting points, magnetic susceptibility, and thermal analyses have been carried out for insuring the chelation process. The antimicrobial activity was carried out against Monilinia fructicola, Aspergillus flavus, Penicillium italicum, Botrytis cinerea, Escherichia coli, Bacillus cereus, Pseudomonas fluorescens, and P. aeruginosa. The radical scavenging activity (RSA%) was in vitro evaluated using ABTS method. FT-IR spectra indicated that GMFX-o-phdn chelated with metal ions as a tetradentate through oxygen of carboxylate group and nitrogen of azomethine group. The data of infrared, 1H NMR, and molar conductivity indicate that GMFX-o-phdn reacted as neutral tetra dentate ligand (N2O2) with metal ions through the two oxygen atoms of the carboxylic group (oxygen containing negative charge) and two nitrogen atoms of azomethine group (each nitrogen containing a lone pair of electrons) (the absent of peak corresponding to ν(COOH) at 1715 cm-1, the shift of azomethine group peak from 1633 cm-1 to around 1570 cm-1, the signal at 11 ppm of COOH and the presence of the chloride ions outside the complex sphere). Thermal analyses (TG-DTG/DTA) exhibited that the decaying of the metal complexes exists in three steps with the final residue metal oxide. The obtained data from DTA curves reflect that the degradation processes were exothermic or endothermic. Results showed that some of the studied complexes exhibited promising antifungal activity against most of the tested fungal pathogens, whereas they showed higher antibacterial activity against E. coli and B. cereus and low activity against P. fluorescens and P. aeruginosa. In addition, GMFX-o-phdn and its metal complexes showed strong antioxidant effect. In particular, the parent ligand and Fe(III) complex showed greater antioxidant capacity at low tested concentrations than that of other metal complexes where their IC50 were 169.7 and 164.6 µg/mL, respectively.

Biochemical Characterization, Phytotoxic Effect and Antimicrobial Activity against Some Phytopathogens of New Gemifloxacin Schiff Base Metal Complexes

String of Fe(III), Cu(II), Zn(II) and Zr(IV) complexes were synthesized with tetradentateamino Schiff base ligand derived by condensation of ethylene diamine with gemifloxacin. The novel Schiff base (4E,4'E)-4,4'-(ethane-1,2-diyldiazanylylidene)bis{7-[(4Z)-3-(aminomethyl)-4-(methoxyimino)pyrrolidin-1-yl]-1-cyclopropyl-6-fluoro-1,4-dihydro-1,8-naphthyridine-3-carboxylic acid} (GMFX-en) and its metal complexes were identified and confirmed by elemental analyses, FT-IR, UV/VIS, ¹ H-NMR spectra, magnetic susceptibility, conductometric measurements and thermal analyses. The FT-IR spectral data showed the chelation behavior of GMFX-en toward the metal ions through oxygen of carboxylate group and nitrogen of azomethine group. In the light of all spectral data, these complexes presumably have octahedral geometry configurations. Thermal analysis specified that the decaying of the metal complexes exist in two or three steps with the final residue metal oxides. Antimicrobial activity of the new prepared metal complexes was screened against some common phytopathogens and their mode of action has been also discussed. The potential phytotoxic effectiveness of the new complexes was furthermore inspected on two commonly experimental plants. The complexes showed significant antimicrobial and phytotoxic effects against the majority of tested phytopathogens and the two tested plants, respectively. The potential antimicrobial activity of the complexes proved their possibility to be used successfully in agropharmacutical industry to control many serious phytopathogens. The phytotoxicity of the studied complexes also indicated their possibility as potential bio-based herbicides alternatives to weed control in crop fields.

Hospitalization Costs and Length of Stay in Chinese Naval Hospitals Between 2008 and 2016 Based on Influencing Factors: A Longitudinal Comparison

INTRODUCTION

A retrospective review conducted in three hospitals of Guangdong and Hainan, China. To analyze the variation tendency of mean hospitalization costs and length of stay (LOS) in naval hospitals over nine years, paying special attention to the factors affecting hospitalization costs and LOS to provide a reference base for health resource allocation in naval hospitals.

MATERIALS AND METHODS

A total of 21,375 cases of military patients who were hospitalized and treated in three naval hospitals between January 2008 to December 2016 were extracted from the military health system. There were 16,278 complete and effective cases during those nine years. The situation, trends, and factors influencing hospitalization costs and LOS were analyzed using descriptive statistics, Mann-Whitney U test, Kruskal-Wallis H test, and multiple linear regressions.

RESULTS

The following factors showed statistically significant differences in hospitalization costs: special care, primary care, year, military rank, critical illness, allergies, and condition (p < 0.0001); and number of hospitalizations, gender, and age (p < 0.01). The following factors showed statistically significant differences in hospital LOS: year, number of hospitalizations, outcomes, military rank, special care, severity of illness, and condition (p < 0.0001); allergy (p < 0.01); and service and gender (p < 0.05). LOS between 2008-2016 showed a decreasing tendency, while hospitalization costs showed an increasing trend. There were 6 factors that affected Abstract (or Structured Summary) both the cost of hospitalization and LOS: special care, year, military rank, condition, allergy, and gender.

CONCLUSIONS

The results suggest that improving efficiency of military hospital require strengthening hierarchical referrals and controlling hospital LOS. Shortening LOS, optimizing clinical pathways, and reasonably controlling the costs associated with medicines and surgery can help reduce hospitalization costs for military patients. Controlling the growth of hospitalization costs can help avoid the physical and psychological burden of medical over-treatment on patients and may also optimize the allocation of military health resources.

Ventilator for the management of patients with severe pneumonia: A protocol of systematic review

BACKGROUND

This study will assess the efficacy and safety of ventilator for the management of severe pneumonia (SP).

METHODS

This study will search the following electronic databases in MEDLINE, EMBASE, Web of Science, PsycINFO, Cochrane Library, CNKI, and Scopus from the beginning to present without language restrictions. Two authors will screen all records according to the eligibility criteria; assess study quality; and extract all essential data from eligible studies. If sufficient studies are included, we will pool the extracted data and carry out meta-analysis.

RESULTS

This study will summarize published studies to assess the efficacy and safety of ventilator for patients with SP.

CONCLUSION

The results of this study may supply a genuine understanding of perspective from a scientific basis on ventilator for the management of patients with SP.

Pharmacokinetics and pharmacodynamics of levofloxacin in bronchial mucosa and lung tissue of patients undergoing pulmonary operation

Levofloxacin is a major antimicrobial agent that is used for the treatment of community-acquired lower respiratory tract infections (LRTIs). The present study was designed to investigate the pharmacokinetics (PK) and pharmacodynamics (PD) of levofloxacin in bronchial mucosa and lung tissue. A total of 32 patients undergoing pulmonary surgery were randomly assigned to one of four groups (8 subjects/group). All patients received a single dose of 500 mg levofloxacin orally prior to the operation. Blood, lung tissue and bronchial mucosa samples were collected prior to treatment and at 1.5, 4, 8, 12 and 24 h following treatment. The drug concentration was determined and PK and PD profiles were calculated using MATLAB software. The peak concentration of levofloxacin was 7.0±1.2 µg/g in lung tissues and 9.4±2.1 µg/g in bronchial mucosa. The corresponding area under the curve between 0 and 24 h (AUC0-24) was 85.7±8.5 and 137.3±19.4 µg h/g. The mean permeability of levofloxacin (ratio of concentration in tissue to that in plasma) was 2.4 in lung tissue and 4.4 in the bronchial mucosa. The PK profiles of levofloxacin in the plasma, lung and bronchial mucosa were described using an integrated one-compartment model. The probability of fAUC0-24/minimal inhibitory concentration (MIC) target attainment of levofloxacin against Streptococcus pneumoniae in the lung and bronchial mucosa was maintained at 100% when MIC ≤1 mg/l, while the cumulative fraction of fAUC0-24/MIC in the corresponding tissues was 94.4 and 98.1%, respectively. The present study demonstrated the high permeability of levofloxacin in the lung and bronchial mucosa of patients undergoing pulmonary surgery. In conclusion, treatment using 500 mg levofloxacin exhibits good clinical and microbiological efficacy for use in LRTIs that are caused by S. pneumoniae. This trial was registered retrospectively in the Chinese Clinical Trial Registry on January 13, 2020 (registration no. ChiCTR2000029096).

Biological Investigations and Spectroscopic Studies of New Moxifloxacin/Glycine-Metal Complexes

Two novel ligand-metal complexes were prepared through the reaction of Zn(II) and Sn(II) with moxifloxacin (MOX) in the presence of glycine (Gly) to investigate their biological activities. IR, UV/VIS and ¹ H-NMR analysis have been carried out for insuring the chelation process. Results suggested that MOX and Gly react with the metal ions through the carbonyl oxygen atom and the oxygen atom of the carboxylic group of MOX and Gly. The antimicrobial activity was carried out against some common bacterial and fungal pathogens and the radical scavenging activity (RSA%) was evaluated using DPPH and ABTS methods. Phytotoxic effect of the prepared complexes was evaluated in vitro against Raphanus raphanistrum and Lepidium sativum. Hemolytic activity was tested against cell membrane of erythrocytes. Results showed that the two prepared complexes exhibited high antimicrobial activity against all tested phytopathogens and no significant phytotoxic effect has been observed. Only MOX-Zn(II) complex showed moderate hemolysis at 100 % concentration.

Synthesis, Spectroscopic, and Biological Studies of Mixed Ligand Complexes of Gemifloxacin and Glycine with Zn(II), Sn(II), and Ce(III)

Three novel mixed ligand metal complexes have been synthesized by the reaction of Zn(II), Sn(II), and Ce(III) with gemifloxacin (GMFX) in the presence of glycine (Gly) (1:1:1 molar ratio). The coordination possibility of the two ligands toward metal ions has been proposed in the light of elemental analysis, molar conductance, spectral infrared (IR), ultraviolet-visible (UV-Vis) and proton-nuclear magnetic resonance (¹H NMR), and magnetic studies. Results suggest that GMFX and Gly interact with the metal ions as bidentate ligands. Electronic and magnetic data proposed the octahedral structure for all complexes under investigation. Antibacterial screening of the compounds was carried out in vitro against two Gram-positive bacteria, Clavibacter michiganensis and Bacillus megaterium, and two Gram-negative bacteria, Escherichia coli and Xanthomonas campestris. Antifungal activity was performed in vitro against Rhizoctonia solani, Sclerotinia sclerotiorum, Aspergillus niger, Botrytis cinerea, and Penicillium digitatum. The ligands and their complexes were also screened for their antioxidant activity. Results showed that some metal complexes showed more biological efficiency than the parent GMFX drug.

Cost-effectiveness analysis of oral versus intravenous drip infusion of levofloxacin in the treatment of acute lower respiratory tract infection in Chinese elderly patients

Aim

Pharmacoeconomic cost-effectiveness analysis of two different dosage regimens of levofloxacin in the treatment of acute lower respiratory tract infection in elderly patients.

Methods

A total of 108 elderly patients with acute lower respiratory tract infection who visited by our hospital between September 2013 and September 2014 were randomly divided into Group A and Group B, with 54 patients in each group. In Group A, levofloxacin injection was given for continuous intravenous infusion treatment, whereas in Group B, levofloxacin injection and levofloxacin capsule were given as sequential therapy (ST). The period of treatment for both the groups was 10 days, and minimum cost analysis was used to analyze the treatment.

Results

Groups A and B had cure rates of 61.1% and 59.3% (P>0.05), effective rates of 88.9% and 83.3% (P>0.05), bacterial clearance rates of 96.3% and 92.6% (P>0.05), and incidence rates of adverse reactions of 7.4% and 3.7% (P>0.05), respectively. Treatment costs of Groups A and B were 1,588 RMB and 1,150 RMB, respectively, whereas the cost-effectiveness of the two groups was at 17.86 and 13.81, respectively (P<0.05).

Conclusion

Levofloxacin ST had relatively higher cost-effectiveness ratio for the treatment of acute lower respiratory tract infection in elderly patients, especially Chinese.

A Prospective Study of the Efficacy, Safety and Pharmacokinetics of Enteral Moxifloxacin in the Treatment of Hemodialysis Patients with Pneumonia

Objectives To investigate the efficacy of oral moxifloxacin (MFLX) as a treatment for pneumonia in hemodialysis (HD) patients and the pharmacokinetic (PK) profile of MFLX after oral administration. Methods Thirteen adult patients who required HD due to chronic renal failure were enrolled in the present study, which was performed to investigate the treatment of community-acquired pneumonia in HD patients. A standard dose of MFLX (400 mg, once daily) was administered. The therapy was continued, discontinued, or switched to another antibiotic depending on the response of the pneumonia to MFLX. A population PK model was developed using the post-hoc method. Results In total, 13 HD patients with pneumonia (male, n=7; female, n=6) were enrolled in the present study. The evaluation on the 3rd day showed that treatment was successful in 11 patients (84.6%) and that 10 patients were cured (76.9%). In the one case in which MFLX treatment failed, the patient was cured by switching to ceftriaxone (CTRX) (2 g, intravenously) plus levofloxacin (LVFX) (250 mg, orally). The causative bacterium in this male patient was P. aeruginosa. It did not display resistance to fluoroquinolones. One patient had liver dysfunction due to MFLX. The estimated PK parameters of MFLX were as follows: AUC_0→24, 61.04±17.74 μg h/mL; C_max, 5.25±1.12 μg/mL; and C_trough, 1.15±0.45 μg/mL. The PK parameters of MFLX among the patients in whom adverse events occurred or in whom a cure was not achieved did not differ from those of the other patients to a statistically significant extent. Conclusion MFLX showed good efficacy and safety in HD patients with community-acquired pneumonia and the results of the PK analysis were favorable. Further prospective studies with larger numbers of patients will be needed to draw definitive conclusions.

Hospital Treatment Costs and Factors Affecting These Costs in Community-Acquired Pneumonia

OBJECTIVES

Community-acquired pneumonia (CAP) accounts for an important part of hospital admissions and health expenses worldwide. The cost increases when treated in a hospital, and reports on this issue are limited in Turkey. This study aimed to investigate direct hospital costs and factors affecting these costs for patients who were hospitalized in our clinic because of the diagnosis of CAP.

MATERIAL AND METHODS

The records of patients who had been hospitalized for the diagnosis of CAP were retrospectively reviewed. Demographic features, radiological features, pneumonia severity index (PSI), CURB-65 scorings, duration of hospitalization, treatments, and the results of treatments were examined. Total hospitalization costs and the expenses for intervention, medication, examinations, and additional services were recorded. The effect of data on the cost was evaluated.

RESULTS

The study was conducted with 87 patients with CAP. The mean duration of hospitalization was 15.6 days and nine patients (10.3%) were exitus. The median total hospital cost was 2062 (451-11690) TL [952 euros (€), 1305 dollars ($)], and the median hospitalization expense per day was 148 Turkish Lira (TL) (68.3 €, 93.7 $). Medication expenses and total cost were higher in male patients than in female patients. Abscess/necrotizing pneumonia increased the cost depending on the infiltration that occurred either alone or with parapneumonic pleurisy. Whereas an increase in the PSI stage increased the total cost and expenses for intervention and medication, medication expenses increased in patients with CURB-65 score of 3 and 4 (p<0.05). Age, smoking, and low oxygen saturation level did not affect the cost. No statistically significant difference was found between the expenses of exitus patients and the expenses of patients who recovered.

CONCLUSION

CAP can lead to high costs and result in death. In our study, it was concluded that the cost increased in male patients, patients with abscess/necrotizing pneumonia, and patients with high PSI scores.

Differences in distribution and drug sensitivity of pathogens in lower respiratory tract infections between general wards and RICU

BACKGROUND

Lower respiratory tract infections (LRTIs) are common among patients in hospitals worldwide, especially in patients over the age of 60. This study investigates the differences in distribution and drug sensitivity of pathogens in LRTIs.

METHODS

The clinical and laboratory data of 4,762 LRTI patients in the general ward and respiratory intensive care unit (RICU) of Xiangya Hospital (Changsha) were retrospectively analyzed.

RESULTS

The infection rate of Gram-negative bacteria was significantly higher than that of Gram-positive bacteria in both the general ward and RICU (P<0.05). The incidence of Gram-negative bacteria infection was significantly higher in the RICU than in the general ward (P<0.05), whereas the incidence of Gram-positive bacteria infection is less in the RICU than in the general ward (P<0.05). In the general ward, the incidence of Gram-negative bacteria infection significantly increased (P<0.05) over time, whereas the incidence of Gram-positive bacteria infection significantly decreased from 1996 to 2011 (P<0.05). In the RICU, the incidence of Gram-positive bacteria infection decreased, while Gram-negative bacteria infections increased without statistical significance (P>0.05). Staphylococcus pneumoniae and Staphylococcus aureus were found to be the predominant Gram-positive strains in the general ward (34.70-41.18%) and RICU (41.66-54.87%), respectively (P>0.05). Pseudomonas aeruginosa and Acinetobacter baumannii were the predominant gram negative strains in the general ward (19.17-21.09%) and RICU (29.60-33.88%), respectively (P>0.05). Streptococcus pneumoniae is sensitive to most antibiotics with a sensitivity of more than 70%. Staphylococcus aureus is highly sensitive to vancomycin (100%), linezolid (100%), chloramphenicol (74.36-82.19%), doxycycline (69.57-77.33%), and sulfamethoprim (67.83-72.46%); however, its sensitivity to other antibiotics is low and decreased each year. Sensitivity of Pseudomonas aeruginosa to most β-lactam, aminoglycoside, and quinolone group antibiotics decreased each year.

CONCLUSIONS

The distribution and drug sensitivity of LRTI pathogens exhibit a high divergence between the general ward and RICU. Streptococcus pneumoniae may not be the predominant pathogen in LRTIs in some areas of China.

Gemifloxacin mesylate (GFM): dissolution test based on in vivo data

Gemifloxacin mesylate (GFM) is a synthetic, broad-spectrum, fluoroquinolone antibacterial agent. It is different from other class members because it achieves adequate plasma concentrations to inhibit both topoisomerase IV and gyrase. The aim of this study was to develop and validate a dissolution test for GFM in coated tablets, using a simulated absorption profile based on in vivo data obtained from the literature. The fraction and percentage of the dose absorbed were calculated using model-dependent Loo-Riegelman approach for two compartments. The best in vitro dissolution profile was obtained using 900 mL of pH 6.0 phosphate buffer as a dissolution medium at 37 °C ± 0.5 °C and paddles at 50 rpm. The in vitro dissolution samples were analyzed using a liquid chromatography method, and the validation was performed according to USP 34 (2011). The method showed specificity, precision, accuracy, robustness and linearity. Under these conditions, a level-A in vitro-in vivo correlation was suggested (r = 0.9926). The prediction errors were calculated to determine the validity and accuracy of the suggested correlation. The dissolution test can be used to evaluate the dissolution profile of GFM-coated tablets and minimize the number of bioavailability studies as part of new formulation development.

Population pharmacokinetics and pharmacodynamic evaluation of intravenous and enteral moxifloxacin in surgical intensive care unit patients

OBJECTIVES

To describe the plasma concentration-time profile of moxifloxacin after intravenous and enteral administration in intensive care unit (ICU) patients and to provide a pharmacodynamic (PD) evaluation with regard to pneumonia.

PATIENTS AND METHODS

Twenty-five adult patients from a cardiothoracic/mixed surgical ICU were enrolled. Moxifloxacin was given as a standard dose (400 mg once daily). Therapy was successfully switched to enteral administration on day 5 in 16 patients. A rich data sampling schedule was performed after intravenous (day 4) and enteral (day 8) administration. Moxifloxacin concentrations were analysed by HPLC. A population pharmacokinetic (PK) model was developed using NONMEM VII. Simulated concentration-time profiles were evaluated for their probability of attaining PK/PD target values relevant for community-acquired pneumonia (CAP) and hospital-acquired pneumonia (HAP).

RESULTS

A linear-elimination two-compartment model described the data adequately. Parameter estimates (coefficient of variation of inter-individual variability) were: absorption rate constant, 1.09/h (135%); enteral bioavailability, 76% (20.0%); central volume of distribution, 55.6 L; peripheral volume of distribution, 59.6 L (15.3%); inter-compartmental clearance, 47.7 L/h; and clearance, 11.3 L/h (23.7%). Both intravenously and enterally administered standard-dose moxifloxacin reliably attained the PK/PD target values for pathogens with MICs ≤ 0.25 mg/L for CAP and ≤ 0.125 mg/L for HAP.

CONCLUSIONS

Drug exposure to moxifloxacin in ICU patients was more variable than in healthy volunteers. The standard dosing provides sufficient drug exposure for treatment of CAP but for HAP it does so only when a highly susceptible pathogen is present. Intravenous/enteral sequential therapy may be considered for cautiously selected cases in ICU patients.

High-dose levofloxacin in community-acquired pneumonia: a randomized, open-label study

BACKGROUND

The conventional treatment for community-acquired pneumonia (CAP) involves combination therapy consisting of a β-lactam penicillin or a cephalosporin with a macrolide. Alternatively, high-dose levofloxacin treatment has been used as single-agent therapy for treating CAP, covering atypical pathogens.

OBJECTIVE

This study compared the clinical efficacy and safety of high-dose levofloxacin with combined ceftriaxone and azithromycin for the treatment of CAP.

PATIENTS AND METHODS

This phase IV, prospective, randomized, open-label trial enrolled patients admitted to a tertiary referral hospital for CAP treatment from 2010 to 2011. Hospital admission was decided based on clinical judgement and the pneumonia severity index. Forty subjects were enrolled and assigned to two treatment arms using a random numbers table. The 20 subjects in the experimental group were given levofloxacin 750 mg intravenously once daily, followed by the same dose of oral levofloxacin at discharge when clinically improved and the 20 subjects in the control group were given ceftriaxone 2.0 g intravenously once daily plus oral azithromycin 500 mg for 3 consecutive days, followed by oral cefpodoxime 200 mg per day at discharge after clinical improvement. The primary outcome was the clinical success rate. Secondary outcomes were the microbiological success rate and adverse events during the study.

RESULTS

Of the 40 subjects enrolled, 36 completed the study: 17 in the experimental group and 19 in the control group. The groups did not differ in terms of demographic factors or clinical findings at baseline. The clinical success rate (cured + improved) was 94% in the experimental (levofloxacin) group and 84% in the control group (p > 0.05). The microbiological success rate and overall adverse events were also similar in both groups.

CONCLUSION

Single-agent, high-dose levofloxacin treatment exhibited excellent clinical and microbiological efficacy with a safety profile comparable to that of ceftriaxone plus azithromycin therapy. Large-scale clinical trials are required to verify these results.

CLINICAL TRIAL REGISTRATION

WHO International Clinical Trials Registry: KCT0000374; Daiichi-Sankyo Korea study code: T11-13-V1.

Moxifloxacin safety: an analysis of 14 years of clinical data

Background

Moxifloxacin, a fluoroquinolone antibiotic, is used for the treatment of respiratory tract, pelvic inflammatory disease, skin, and intra-abdominal infections. Its safety profile is considered favorable in most reviews but has been challenged with respect to rare but potentially fatal toxicities (e.g. hepatic, cardiac, or skin reactions).

Objective

To analyze and compare the safety profile of moxifloxacin versus comparators in the entire clinical database of the manufacturer.

Setting

Data on the valid-for-safety population from phase II–IV actively controlled studies (performed between 1996 and 2010) were analyzed. Studies were either double blind (n = 22 369) or open label (n = 7635) and included patients with indications that have been approved in at least one country [acute bacterial sinusitis, acute exacerbation of chronic bronchitis, community-acquired pneumonia, uncomplicated pelvic inflammatory disease, complicated and uncomplicated skin and skin structure infections, and complicated intra-abdominal infections] (n = 27 824) and patients with other indications (n = 2180), using the recommended daily dose (400 mg) and route of administration (oral, intravenous/oral, intravenous only). The analysis included patients at risk (age ≥65 years, diabetes mellitus, renal impairment, hepatic impairment, cardiac disorders, or body mass index <18 kg/m²). Patients with known contraindications were excluded from enrollment by study protocol design, but any patient having entered a study, even if inappropriately, was included in the analysis.

Main Outcome Measure

Crude incidences and relative risk estimates (Mantel-Haenszel analysis) of patients with any adverse event (AE), adverse drug reaction (ADR), serious AE (SAE), serious ADR (SADR), treatment discontinuation due to an AE or ADR, and fatal outcomes related to an AE or ADR.

Results

Overall incidence rates of AEs were globally similar in the moxifloxacin and comparator groups. By filtering the data for differences in disfavor of moxifloxacin (i) at ≥2.5% for events with an incidence ≥2.5% or at ≥2-fold for events with an incidence <2.5% in one or both groups and (ii) affecting ≥10 patients in either group, we observed slightly more (i) AEs in double-blind intravenous-only and open-label oral studies, (ii) SAEs in double-blind intravenous-only studies, (iii) ADRs and SADRs in open-label oral studies, (iv) SADRs in open-label intravenous/oral studies, and (v) premature discontinuation due to AEs in open-label intravenous-only studies. The actual numbers of SADRs (in all studies) were small, with clinically relevant differences noted only in intravenous/oral studies and mainly driven by ‘gastrointestinal disorders’ (15 versus 7 patients) and ‘changes observed during investigations’ (23 versus 7 patients [asymptomatic QT prolongation: 11 versus 4 patients in double-blind studies]). Analysis by comparator (including another fluoroquinolone) did not reveal medically relevant differences, even in patients at risk. Incidence rates of hepatic disorders, tendon disorders, clinical surrogates of QT prolongation, serious cutaneous reactions, and Clostridium difficile-associated diarrhea were similar with moxifloxacin and comparators.

Conclusion

The safety of moxifloxacin is essentially comparable to that of standard therapies for patients receiving the currently registered dosage and for whom contraindications and precautions of use (as in the product label) are taken into account.

High-dose levofloxacin in community-acquired pneumonia: a randomized, open-label study

BACKGROUND

The conventional treatment for community-acquired pneumonia (CAP) involves combination therapy consisting of a β-lactam penicillin or a cephalosporin with a macrolide. Alternatively, high-dose levofloxacin treatment has been used as single-agent therapy for treating CAP, covering atypical pathogens.

OBJECTIVE

This study compared the clinical efficacy and safety of high-dose levofloxacin with combined ceftriaxone and azithromycin for the treatment of CAP.

PATIENTS AND METHODS

This phase IV, prospective, randomized, open-label trial enrolled patients admitted to a tertiary referral hospital for CAP treatment from 2010 to 2011. Hospital admission was decided based on clinical judgement and the pneumonia severity index. Forty subjects were enrolled and assigned to two treatment arms using a random numbers table. The 20 subjects in the experimental group were given levofloxacin 750 mg intravenously once daily, followed by the same dose of oral levofloxacin at discharge when clinically improved and the 20 subjects in the control group were given ceftriaxone 2.0 g intravenously once daily plus oral azithromycin 500 mg for 3 consecutive days, followed by oral cefpodoxime 200 mg per day at discharge after clinical improvement. The primary outcome was the clinical success rate. Secondary outcomes were the microbiological success rate and adverse events during the study.

RESULTS

Of the 40 subjects enrolled, 36 completed the study: 17 in the experimental group and 19 in the control group. The groups did not differ in terms of demographic factors or clinical findings at baseline. The clinical success rate (cured + improved) was 94% in the experimental (levofloxacin) group and 84% in the control group (p > 0.05). The microbiological success rate and overall adverse events were also similar in both groups.

CONCLUSION

Single-agent, high-dose levofloxacin treatment exhibited excellent clinical and microbiological efficacy with a safety profile comparable to that of ceftriaxone plus azithromycin therapy. Large-scale clinical trials are required to verify these results.

CLINICAL TRIAL REGISTRATION

WHO International Clinical Trials Registry: KCT0000374; Daiichi-Sankyo Korea study code: T11-13-V1.

How important is age in defining the prognosis of patients with community-acquired pneumonia?

PURPOSE OF REVIEW

Given that the population is increasing in age, a better understanding of the relationship between chronological age and health-related outcomes (especially mortality) is needed, for both chronic diseases (e.g. diabetes) and acute illnesses (e.g. pneumonia). Our purpose was to review the impact of age on the prognosis of patients with community-acquired pneumonia (CAP).

RECENT FINDINGS

Many studies in patients with CAP have suggested that chronological age is not necessarily independently associated with mortality. Poorer outcomes in the elderly with CAP have been related to severity of disease, comorbid disease burden, functional status, and frailty, but not to age alone. However, many of these studies suffer from 'over-adjustment' due to the use of unmodified severity scores such as the Pneumonia Severity Index or Acute Physiology and Chronic Health Evaluation II (that already include age) in multivariable analyses. Studies accounting for this over-adjustment suggest that age is, in fact, independently associated with mortality in hospitalized patients with CAP. Other outcomes including hospitalization and readmission rates, hospital length of stay, and cost of care are similarly associated with increasing age. Residual confounding is still a problem in many of the observational studies reviewed.

SUMMARY

Contrary to conventional wisdom, chronological age is independently associated with adverse outcomes in patients with CAP. Until better methods (or more clinically-rich datasets) for observational studies are developed that can avoid over-adjustment and better deal with residual confounding, physicians should take into account both a patient's overall health status and his or her chronological age.

Evidence for moxifloxacin in community-acquired pneumonia: the impact of pharmaco-economic considerations on guidelines

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.

Bench-to-bedside review: Appropriate antibiotic therapy in severe sepsis and septic shock--does the dose matter?

Appropriate antibiotic therapy in patients with severe sepsis and septic shock should mean prompt achievement and maintenance of optimal exposure at the infection site with broad-spectrum antimicrobial agents administered in a timely manner. Once the causative pathogens have been identified and tested for in vitro susceptibility, subsequent de-escalation of antimicrobial therapy should be applied whenever feasible. The goal of appropriate antibiotic therapy must be pursued resolutely and with continuity, in view of the ongoing explosion of antibiotic-resistant infections that plague the intensive care unit setting and of the continued decrease in new antibiotics emerging. This article provides some principles for the correct handling of antimicrobial dosing regimens in patients with severe sepsis and septic shock, in whom various pathophysiological conditions may significantly alter the pharmacokinetic behaviour of drugs.

Serious Antimicrobial Resistance Status of Pathogens Causing Hospital-acquired Lower Respiratory Tract Infections in North China

Antimicrobial resistance patterns of pathogens causing hospital-acquired lower respiratory tract infections (LRTIs) in Shandong Province, China were investigated using data collected from January 2002 to December 2006. A total of 10337 isolates were characterized in sputum samples from 39 920 LRTI patients: 68.72% were Gram-negative bacteria, 20.65% were Gram-positive bacteria, and 10.62% were fungi. Organisms most frequently isolated were: Pseudomonas aeruginosa (16.88%), Klebsiella pneumoniae (10.80%), Escherichia coli (10.71%), fungi (10.62%), Staphylococcus aureus (9.68%) and Acinetobacter baumannii (9.03%). Imipenem was the most effective antibiotic against Gram-negative bacteria. Most Gram-positive bacteria were susceptible to vancomycin. Susceptibility to cephalosporins was not optimal and resistance to fluoroquinolones was high. Resistance of Gram-negative bacteria showed a rapid increase over the study period, while resistance of Gram-positive bacteria remained relatively stable. The emergence of resistance to commonly prescribed antimicrobial agents used against LRTI pathogens has compounded the problem of using empirical therapy and created selective pressure on physicians to use certain antibiotics.

Review: Novel targets in the management of pneumonia

Community-acquired pneumonia (CAP) is the leading cause of death from infectious diseases in the US. It accounts each year for 500,000 hospitalizations and 45,000 deaths and represents one of the most common causes of intensive care unit (ICU) admission. The mortality rate due to severe CAP has shown little improvement in the past three decades, remaining between 21% and 58% in patients admitted to the intensive care unit. Antimicrobial agents are the cornerstone of therapy against CAP, but there are some novel antibiotic and nonantibiotic therapies that have been recently tested that may potentially impact outcomes of patients with severe CAP. We will review the most recent data regarding novel therapies in patients with the highest risk of death such as those with severe CAP.

Gatifloxacin biodegradable implant for treatment of experimental osteomyelitis: in vitro and in vivo evaluation

Osteomyelitis is an inflammatory bone disease caused by pyogenic bacteria. The advantages of localized biodegradable therapy for osteomyelitis include high local antibiotic concentration at the site of infection and obviation of the need for removal of the implant after treatment. The purpose of this study was to develop and evaluate a biodegradable implantable delivery system containing gatifloxacin (GAT) for the localized treatment of osteomyelitis, experimentally induced by methicillin resistant Staphylococcus aureus (MRSA). Implants, prepared by solvent casting technique, showed reasonable tensile strength. DSC examination indicated that GAT is present in an amorphous form in the implant. The in vitro release of GAT showed a profile characterized by an initial burst followed by a second stage of gradual delivery over 27 days. The in vivo release study revealed that GAT concentrations achieved during the first 3 weeks after implantation exceeded the MIC of GAT against MRSA by > 100,000 times. Bacterial tibial bone count performed in rabbits tibia 2 and 4 weeks after implantation of GAT implant in infected bone indicated complete eradication of infection in all treated rabbits as indicated by the significant decrease in bacterial count. The results show that the proposed implant may have a promising role in the therapeutic approach to osteomyelitis.

Implementing a hospital guideline on pneumonia: a semi-quantitative review

BACKGROUND AND OBJECTIVE

To quantify the impact of different guideline implementation interventions to improve treatment of community-acquired pneumonia (CAP) in a hospital setting.

METHODS

Pubmed, the Cochrane Library, the Cochrane Effective Practice and Organization of Care specialized register, EMBASE and CINAHL.

STUDY SELECTION

Hospital-based trials studying the effect of guidelines on compliance with care processes, clinical and/or economic outcomes in the treatment of CAP together with a description of their implementation interventions.

DATA EXTRACTION

Two independent reviewers extracted and categorized utilized implementation interventions, assessed intensity of use and calculated changes for process of care variables, clinical and economical outcomes. Correlations between interventions and improvement of outcomes were assessed by means of Spearman's rho-test and Mann-Whitney U-test.

RESULTS

In 27 included studies, educational meetings (21/27) and distribution of written material (14/27) were the two most used interventions. Most individual studies show positive overall results, but taken together, no significant relation between number or type of implementation interventions and improvement of outcomes could be detected. Only audit and feedback showed a significant negative influence on the improvement rate of length of stay (p = 0.003; n = 20).

CONCLUSION

Other hospital-specific factors are likely to have a higher impact on the rate of improvement than the implementation interventions alone. Describing which interventions are most successful is unlikely to be correct without taking these hospital-specific factors into account. Future research should focus on how to identify and define these factors and how to adapt the intervention to hospital-specific factors.

[Clinically significant toxicity and tolerance of the main antibiotics used in lower respiratory tract infections]

The purpose of this article was not to review all reported adverse reactions of antibiotics used in the treatment of lower respiratory tract infections but rather to focus either on those which might have an impact on observance, efficacy, and resistance, or on rare but life-threatening adverse effects such as torsade de pointe. The latter are mostly predictable and prescribers should adhere to precautions and contraindications. For new antibiotics, the number of patients enrolled in phase I to III clinical trials is far to small to detect such rare adverse effects and large post registration tolerance surveys are mandatory. ss-lactams are well tolerated. The risk of anaphylactic reaction is magnified by patient reports and can be reduced by skin testing. Macrolides are well tolerated as well. The risk of cardiac toxicity should be reduced by assessing individual susceptibility and avoiding drug interactions. The tolerance to telithromycin, a new ketolide, is similar to that of macrolides. Serious toxic reactions such as convulsions, tendon rupture, torsade de pointe, and hypoglycemia are associated with the use of fluoroquinolones. Most of these adverse reactions can be often circumvented by avoiding exposure patients at risk. Quinupristin/dalfopristin can induce arthralgia and myalgia and the major adverse effects of linezolid are IMAO like reactions, reversible myelosuppression, and peripheral neuropathy. Most of the adverse antibiotic reactions are reported when precautions of use in susceptible patients are not taken into account. When they are, the safety/risk ratio is good.

Principles of antibiotic treatment of community-acquired pneumonia in the outpatient setting

Community-acquired pneumonia (CAP) is a common illness with high rates of morbidity and mortality. Nearly 80% of the treatment for this condition is provided in the outpatient setting. Among the etiologic agents associated with bacterial CAP, the predominant pathogen is Streptococcus pneumoniae. Treatment of CAP for the most part is empirical; therefore, any antibiotic treatment should cover both typical and atypical pathogens. The beta-lactams have historically been considered standard therapy for the treatment of CAP. However, the impact of rising resistance rates is now a primary concern facing physicians. For patients with comorbidities or recent antibiotic therapy, current guidelines recommend either combination therapy with a beta-lactam and a macrolide or an antipneumococcal fluoroquinolone alone. Fluoroquinolones are broad-spectrum antibiotics that exhibit high levels of penetration into the lungs and low levels of resistance. Evidence from clinical trials indicates clinical success rates of > 90% for moxifloxacin, gatifloxacin, and levofloxacin in the treatment of CAP due to S pneumoniae. Data from comparative clinical trials suggest fluoroquinolone monotherapy is as efficacious as beta-lactam-macrolide combination therapy in the treatment of CAP patients. The respiratory fluoroquinolone levofloxacin has also been shown to be effective in CAP patients for the treatment of macrolide-resistant S pneumoniae. The use of azithromycin, telithromycin, and fluoroquinolones in short-course regimens has been shown to be efficacious, safe, and tolerable in patients with CAP. Based on clinical evidence, high-dose, short-course therapies may represent a significant advance in the management of CAP.

Appropriate outpatient treatment of acute bacterial exacerbations of chronic bronchitis

Acute exacerbations of chronic bronchitis (AECB), which are characteristic of chronic obstructive pulmonary disease (COPD), contribute to morbidity and decreased quality of life for patients with COPD. A significant proportion of these exacerbations are due to bacterial infections. The Council for Appropriate and Rational Antibiotic Therapy (CARAT) criteria provide guidance for choosing the optimal drug at its optimal dose and duration for antimicrobial treatment of AECB due to bacterial infection. Evidence-based guidelines recommend stratifying patients according to risk factors to improve selection of targeted antimicrobial therapy. With increasing rates of resistance to some antimicrobials, resistance is also an important consideration for reducing treatment failures and decreasing the need for further pharmacologic treatment. Fluoroquinolones are recommended as first-line therapy for patients with chronic bronchitis who have risk factors; gatifloxacin, gemifloxacin, and levofloxacin are highly active against commonly encountered pathogens. Safety profiles are an important consideration because adverse events and poor tolerability can reduce patient adherence rates, which in turn can lead to poorer outcomes. Safety profiles also become an important consideration as shorter-course, higher-dose therapies become more prevalent. First-line therapy with a well-tolerated antibiotic that is active against the predominant pathogens, combined with low resistance rates and a convenient once-a-day dosing regimen, may reduce overall costs. Fluoroquinolones exhibit low resistance, good activity levels, and high respiratory penetration, and they are particularly well suited for shorter-course, higher-dose regimens in selected patients. Shorter-course, higher dose regimens, in turn, may be more effective, cost-efficient, and appropriate for controlling the rise of resistance than standard regimens.

Treatment of rhinosinusitis in the outpatient setting

Rhinosinusitis is one of the most common respiratory tract conditions seen by primary care physicians. Each year approximately 20 million cases of acute bacterial rhinosinusitis (ABRS) occur in the United States. Since diagnosis of ABRS relies on clinical evaluation, treatments are usually empirical and include an antibiotic treatment that covers the common bacteria associated with ABRS infection, Streptococcus pneumoniae and Haemophilus influenzae. The Council for Appropriate and Rational Antibiotic Therapy (CARAT) recommends that antimicrobial therapy for rhinosinusitis should combine high susceptibility, clinical effectiveness, safety, and tolerability. The most efficacious antibiotics for ABRS include the respiratory fluoroquinolones gatifloxacin, levofloxacin, and moxifloxacin, as well as ceftriaxone and amoxicillin-clavulanate. The use of fluoroquinolones or high-dose amoxicillin-clavulanate is recommended for patients with mild disease who have had recent antimicrobial therapy or for patients with moderate disease. These drugs are generally well tolerated with mild adverse effects. Resistance to fluoroquinolones in S pneumoniae and H influenzae has remained low in spite of their increased use. Recent studies indicate that short-course, high-dose treatment regimens may reduce total drug use, improve tolerability and adherence, prevent increases in resistance, and increase efficacy. The use of fluoroquinolones or amoxicillin-clavulanate in a short-course, high-dose regimen may represent an exciting new protocol in the treatment of rhinosinusitis.