Double-blind, randomized study of the efficacy and safety of oral pharmacokinetically enhanced amoxicillin-clavulanate (2,000/125 milligrams) versus those of amoxicillin-clavulanate (875/125 milligrams), both given twice daily for 7 days, in treatment of bacterial community-acquired pneumonia in adults

Exploring the Therapeutic Potential of High Dose Co-amoxiclav (1 gm) in Different Clinical Conditions: A Review

Amoxicillin/clavulanate (co-amoxiclav) is a widely used antibiotic in community healthcare settings, combining amoxicillin and clavulanate potassium to combat β-lactamase-producing bacteria. Despite its extensive use, limited pharmacokinetic/pharmacodynamic data support current dosing guidelines. This review explores the significance of high-dose co-amoxiclav (875 mg/125 mg) in treating various infections amidst rising antibiotic resistance. A comprehensive narrative literature review was conducted using MEDLINE, PubMed, and Google Scholar, focusing on co-amoxiclav 875 mg/125 mg from 1992 to 2024. Keywords included "Co-amoxiclav 875mg/125mg," "amoxicillin 875mg," "Co-amoxiclav dosing," "pharmacology," "PK," and "safety." Studies on non-safety aspects, those on cost-effectiveness, non-English articles, and those without full-text access were excluded. Clinical efficacy studies demonstrate the effectiveness of co-amoxiclav (875 mg/125 mg) in treating conditions such as cutaneous actinomycosis, actinomycetoma, lower respiratory tract infections, acute bacterial maxillary sinusitis, and community-acquired pneumonia. Comparative studies reveal similar or superior efficacy of co-amoxiclav (875 mg/125 mg) compared to other dosing regimens and antibiotics such as clindamycin, cefaclor, cefuroxime, and ciprofloxacin. Safety and tolerability assessments indicate that co-amoxiclav is generally well-tolerated, with common mild-to-moderate gastrointestinal side effects. In summary, co-amoxiclav 1 gm remains a crucial antibiotic with optimized dosing regimens enhancing clinical outcomes while addressing resistance challenges.

Childhood Pneumonia in Low- and Middle-Income Countries: A Systematic Review of Prevalence, Risk Factors, and Healthcare-Seeking Behaviors

Childhood pneumonia is a major contributor to illness and death in children under the age of five globally. Despite advancements in medical science, the burden of pediatric community-acquired pneumonia (CAP) remains high, particularly in low- and middle-income countries. This systematic review aims to synthesize existing literature on the prevalence, risk factors, and healthcare-seeking behaviors associated with pediatric CAP to inform the development of targeted community-based interventions. An extensive search of various databases such as Medline, EMBASE, Web of Science, Cochrane, PubMed, PubMed Central, Helinet, SpringerLink, Google Scholar, and Biomed Central was performed, resulting in 65 potentially relevant studies. After a thorough evaluation process, 25 studies were selected for the final analysis. These selected studies offered valuable information on the epidemiology, risk factors, and healthcare-seeking behaviors associated with childhood pneumonia. The review revealed that environmental factors such as indoor air pollution, overcrowding, and exposure to tobacco smoke are significant risk factors for pediatric pneumonia. Additionally, socioeconomic factors, including poverty and a lack of access to clean water and sanitation, contribute to the vulnerability of children to this disease. Poor healthcare-seeking behaviors, driven by limited knowledge and awareness of pneumonia symptoms and treatment, further exacerbate the situation. The review also highlighted the critical role of vaccination, particularly against Haemophilus influenzae type b (Hib) and pneumococcus, in preventing pneumonia. However, gaps in vaccination coverage and challenges in accessing healthcare services remain barriers to effective pneumonia control. In light of these findings, the review recommends the implementation of community-based interventions that address the multifaceted determinants of pediatric pneumonia. These interventions should focus on improving environmental conditions, enhancing access to preventive measures such as vaccination, and promoting better healthcare-seeking behaviors through education and awareness campaigns. It is essential for healthcare providers, policymakers, and community members to collaborate in developing and implementing culturally appropriate and sustainable interventions. This cooperation aims to lessen the impact of pneumonia on children and their families.

High-dose versus standard-dose amoxicillin/clavulanate for clinically-diagnosed acute bacterial sinusitis: A randomized clinical trial

Background

The recommended treatment for acute bacterial sinusitis in adults, amoxicillin with clavulanate, provides only modest benefit.

Objective

To see if a higher dose of amoxicillin will lead to more rapid improvement.

Design, setting, and participants

Double-blind randomized trial in which, from November 2014 through February 2017, we enrolled 315 adult outpatients diagnosed with acute sinusitis in accordance with Infectious Disease Society of America guidelines.

Interventions

Standard-dose (SD) immediate-release (IR) amoxicillin/clavulanate 875 /125 mg (n = 159) vs. high-dose (HD) (n = 156). The original HD formulation, 2000 mg of extended-release (ER) amoxicillin with 125 mg of IR clavulanate twice a day, became unavailable half way through the study. The IRB then approved a revised protocol after patient 180 to provide 1750 mg of IR amoxicillin twice a day in the HD formulation and to compare Time Period 1 (ER) with Time Period 2 (IR).

Main measure

The primary outcome was the percentage in each group reporting a major improvement—defined as a global assessment of sinusitis symptoms as “a lot better” or “no symptoms”—after 3 days of treatment.

Key results

Major improvement after 3 days was reported during Period 1 by 38.8% of ER HD versus 37.9% of SD patients (P = 0.91) and during Period 2 by 52.4% of IR HD versus 34.4% of SD patients, an effect size of 18% (95% CI 0.75 to 35%, P = 0.04). No significant differences in efficacy were seen at Day 10. The major side effect, severe diarrhea at Day 3, was reported during Period 1 by 7.4% of HD and 5.7% of SD patients (P = 0.66) and during Period 2 by 15.8% of HD and 4.8% of SD patients (P = 0.048).

Conclusions

Adults with clinically diagnosed acute bacterial sinusitis were more likely to improve rapidly when treated with IR HD than with SD but not when treated with ER HD. They were also more likely to suffer severe diarrhea. Further study is needed to confirm these findings.

Trial registration

ClinicalTrials.gov Identifier: NCT02340000.

Evaluation and significance of C-reactive protein in the clinical diagnosis of severe pneumonia

Severe pneumonia is a major cause of mortality in children. The present study evaluated the diagnostic value of serum C-reactive protein (CRP) levels for cases of severe pneumonia. A total of 862 children, hospitalized for acute respiratory tract infections, were evaluated between September 2008 and February 2011; the serum levels of CRP were measured in all the children. Bacterial identification was performed, while polymerase chain reaction was used to detect the 12 respiratory viruses. Multivariate logistic regression analysis was performed with independent [CRP, proportion of neutrophils (NEUT), body temperature, sputum production, age and dyspnea] and dependent (severe and mild pneumonia) variables for clinical diagnosis, which produced three new variables that represented an individual's predictive value: Pre-1, Pre-2 and Pre-3. A receiver operating characteristic (ROC) curve was generated using the new variables to assess their predictive value for severe pneumonia. Of the 862 patients, 108 individuals were diagnosed with severe pneumonia and 754 individuals had mild pneumonia. Increased levels of CRP were associated with severe pneumonia and bacterial infection (P<0.05). Multivariate logistic regression analysis found that severe pneumonia was associated with the levels of CRP, body temperature, expectoration, age, NEUT and dyspnea (P<0.05). The ROC curve of the regression diagnostics model sequentially presented CRP, CRP and the other five correlative variables (NEUT + body temperature + sputum production + age + dyspnea) and the other five correlative variables used to diagnose severe pneumonia. The area under curve values were determined as 0.550 for Pre-1 [95% confidence interval (CI), 0.490-0.609], 0.897 for Pre-2 (95% CI, 0.861-0.932) and 0.893 for Pre-3 (95% CI, 0.855-0.931). The results revealed that the six correlative variables had improved accuracy in the diagnosis of severe pneumonia. The serum levels of CRP were strongly associated with bacterial infection and severe pneumonia. Therefore, the CRP level, along with other parameters, may be used as early indicators of severe pneumonia development. However, the efficiency of the CRP level alone to diagnose severe pneumonia was found to be limited.

Antibiotics for community-acquired pneumonia in adult outpatients

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.

Comparison of adherence between twice- and thrice-daily regimens of oral amoxicillin/clavulanic acid

BACKGROUND AND OBJECTIVE

Few studies have analysed adherence with antibiotic treatment in patients with respiratory tract infections. The aim of this study was to compare the compliance of patients taking a pharmacokinetically enhanced formulation of amoxicillin/clavulanic acid twice daily with that of patients taking the standard formulation thrice daily.

METHODS

Patients with suspected bacterial lower respiratory tract infections, pharyngitis and dental infections were included. Adherence was assessed by electronic monitoring, which recorded every opening of the patient's bottle of pills. The outcome variables were compliance with taking the medication, taking the correct dose and with timing of the dose.

RESULTS

A total of 240 patients were enrolled (167 in the thrice-daily group and 73 in the twice-daily group). The percentage of doses taken was greater with the twice-daily regimen (84.5 ± 22.8%) than with the thrice-daily regimen (72.7 ± 20.1%; P < 0.001). Forty patients in the twice-daily group opened the container every 12 ± 6 h during at least 80% of the course (54.8%), while only 19.6% of the patients assigned to the thrice-daily formulation did so every 8 ± 4 h (P < 0.001). The percentage of patients who opened the container a satisfactory number of times per day was significantly higher among those taking the twice-daily regimen on days three, four, five, six and seven. Moreover, the thrice-daily group more frequently forgot to take the afternoon dose.

CONCLUSIONS

The rate of compliance with amoxicillin/clavulanic acid therapy was very low. However, compliance with the new formulation that is taken twice-daily was significantly better.

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

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

Antibiotic Collateral Damage: Resistance and Antibiotic-Associated Diarrhea

The purpose of this review is to describe dilemmas associated with antibiotic collateral damage and provide clinical pharmacists with information to improve antibiotic utilization. The clinical use of antibiotics has been associated with acquisition and spread of nosocomial pathogens and multidrug-resistant strains, such as extended-spectrum beta-lactamases, AmpC hyper-producers, carbapenemases, and resistant gram-positive organisms. The mobility of plasmid-mediated resistance, such as extended-spectrum beta-lactamases and the more recently isolated Klebsiella pneumoniae carbapenemases, have been well-demonstrated with worldwide distribution across several different species. The challenges surrounding antibiotic-associated diarrhea, particularly Clostridium difficile infection (CDI), continue to evolve with outbreaks of hypervirulent strains linked to the use of less commonly implicated antibiotics. Published literature was searched and reviewed using PubMed. Undesirable attributes related to antibiotic use can have broad consequences in addition to their effect on individual patients. This collateral damage can evolve over time, and prescribers must be aware of current concerns and be diligent in their judicious use of antibiotics.

Biomarkers in the management of pneumonia

A novel approach to improve diagnosis and prognosis of pneumonia is the use of biomarkers. An ideal diagnostic biomarker for pneumonia should allow an early diagnosis and differential diagnosis from other, noninfectious conditions. Procalcitonin (PCT) has emerged as a reliable diagnostic marker in pneumonia, and is better when compared with other markers, namely C-reactive protein, leukocyte count and proinflammatory cytokines. A PCT-based diagnostic and therapeutic strategy can reduce antibiotic usage in patients with pneumonia, mainly by reducing the duration of antibiotic courses. However, PCT should not be used as a substitute for a careful clinical assessment. PCT levels may remain low in localized infections in the context of pneumonia, especially in patients with localized empyema. An ideal prognostic biomarker should be informative about the course and outcome of a disease. Various biomarkers, namely pro-adrenomedullin, natriuretic peptides, endothelin-1 precursor peptides, as well as copeptin and cortisol levels, are promising in this respect. Future studies will show whether an assessment with those novel biomarkers is able to guide prognostic decision-making and improve the allocation of healthcare resources and hospitalization costs.

Antibiotics for community acquired pneumonia in adult outpatients

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.

Pneumococcal antimicrobial resistance: therapeutic strategy and management in community-acquired pneumonia

Streptococcus pneumoniae has been consistently shown to represent the most frequent causative agent of community-acquired pneumonia (CAP) and pneumococcal antibiotic resistance towards different families of antibiotics continues to be a much-debated issue. Microbial resistance causes a great deal of confusion in choosing an empirical treatment for pneumonia and this makes it necessary to know which factors actually determine the real impact of antimicrobial resistance on the outcome of pneumococcal infections. Several different aspects have to be taken into account when analyzing this matter, such as the study design, the condition of the patient at the time of diagnosis, the choice of the initial antimicrobial regimen (combination or monotherapy) and the pharmacokinetic/pharmacodynamic variables of the chosen antibiotic. It is generally accepted that in the treatment of beta-lactam-resistant pneumococcal infections, the use of standard antipneumococcal beta-lactam agents is unlikely to impact negatively on the outcome of CAP when appropriate agents are given in sufficient doses. As a general rule, for infections with penicillin-sensitive strains, penicillin or an aminopenicillin in a standard dosage will be effective; in the cases of strains with intermediate resistance, beta-lactam agents are still considered appropriate treatment although higher dosages are recommended; finally, infections with isolates of high-level penicillin resistance should be treated with alternative agents such as the third-generation cephalosporins or the new antipneumococcal fluoroquinolones. In areas of high prevalence of high-level macrolide resistance, empirical monotherapy with a macrolide is not optimal for the treatment of hospitalised patients with moderate or moderately-severe CAP. Fluoroquinolones are considered to be excellent antibiotics in the treatment of pneumococcal CAP in adults, but their general recommendation has been withheld due to fears of a widespread development of resistance. Most international guidelines recommend combination therapy (beta-lactam plus a macrolide) for the treatment of hospitalised patients with CAP.

Diagnostic and prognostic accuracy of clinical and laboratory parameters in community-acquired pneumonia

Background

Community-acquired pneumonia (CAP) is the most frequent infection-related cause of death. The reference standard to diagnose CAP is a new infiltrate on chest radiograph in the presence of recently acquired respiratory signs and symptoms. This study aims to evaluate the diagnostic and prognostic accuracy of clinical signs and symptoms and laboratory biomarkers for CAP.

Methods

545 patients with suspected lower respiratory tract infection, admitted to the emergency department of a university hospital were included in a pre-planned post-hoc analysis of two controlled intervention trials. Baseline assessment included history, clinical examination, radiography and measurements of procalcitonin (PCT), highly sensitive C-reactive protein (hsCRP) and leukocyte count.

Results

Of the 545 patients, 373 had CAP, 132 other respiratory tract infections, and 40 other final diagnoses. The AUC of a clinical model including standard clinical signs and symptoms (i.e. fever, cough, sputum production, abnormal chest auscultation and dyspnea) to diagnose CAP was 0.79 [95% CI, 0.75–0.83]. This AUC was significantly improved by including PCT and hsCRP (0.92 [0.89–0.94]; p < 0.001). PCT had a higher diagnostic accuracy (AUC, 0.88 [0.84–0.93]) in differentiating CAP from other diagnoses, as compared to hsCRP (AUC, 0.76 [0.69–0.83]; p < 0.001) and total leukocyte count (AUC, 0.69 [0.62–0.77]; p < 0.001). To predict bacteremia, PCT had a higher AUC (0.85 [0.80–0.91]) as compared to hsCRP (p = 0.01), leukocyte count (p = 0.002) and elevated body temperature (p < 0.001). PCT, in contrast to hsCRP and leukocyte count, increased with increasing severity of CAP, as assessed by the pneumonia severity index (p < 0.001).

Conclusion

PCT, and to a lesser degree hsCRP, improve the accuracy of currently recommended approaches for the diagnosis of CAP, thereby complementing clinical signs and symptoms. PCT is useful in the severity assessment of CAP.

Severe pneumococcal pneumonia: new strategies for management

PURPOSE OF REVIEW

Streptococcus pneumoniae is the leading cause of community-acquired pneumonia worldwide and is the most likely causative pathogen in patients with community-acquired pneumonia admitted to the intensive care unit. Bacteremic pneumococcal pneumonia is an advanced stage of severe pneumococcal pneumonia. Improvement in the management of bacteremic pneumococcal pneumonia has the potential for improving the survival for severe pneumococcal pneumonia.

RECENT FINDINGS

Non-culture methods, especially the Binax urinary antigen test, can increase the diagnostic yield for pneumococcal pneumonia, allowing targeted antimicrobial therapy (specifically penicillin). In-vitro resistance to penicillin has increased over the past decade; however, it has not led to clinical failure when used for pneumococcal pneumonia.

SUMMARY

Hospitalized patients with community-acquired pneumonia should have blood cultures obtained to confirm the possibility of bacteremic pneumococcal pneumonia. Based on pharmacodynamic properties, parenteral penicillin remains the drug of choice to treat pneumococcal pneumonia regardless of in-vitro resistance. Combination antimicrobial therapy will likely improve survival of patients with bacteremic pneumococcal pneumonia among the subset of critically ill patients.

Impact of initial discordant treatment with beta-lactam antibiotics on clinical outcomes in adults with pneumococcal pneumonia: a systematic review

OBJECTIVE

To systematically examine the available evidence regarding the effect of initial discordant therapy with beta-lactam antibiotics on mortality, clinical success, and bacteriological eradication in patients with pneumococcal pneumonia.

METHODS

We analyzed prospective studies that compared the clinical effectiveness of concordant (active in vitro) beta-lactam monotherapy with discordant (inactive in vitro) monotherapy with the same beta-lactam in patients with pneumococcal pneumonia. Relevant studies were identified from searches of the PubMed database (1950 to November 2005) and references from articles. Outcomes between groups of patients who received concordant and discordant treatment were compared by simple pooling of data and by estimation of pooled odds ratios or risk difference (RD), when applicable.

RESULTS

Six prospective studies were included in our analysis. No statistically significant difference was found in mortality of patients treated with beta-Iactam concordant and discordant therapy (51/275 [19%] vs 9/42 [21%]; P = .66; data from 6 studies; RD, -0.05; 95% confidence interval [CI], -0.23 to 0.12; data from 5 studies). In addition, no statistically significant difference was found regarding clinical success (37/42 [88%] vs 5/6 [83%]; P = .57; odds ratio, 2.57; 95% CI, 0.46 to 14.34; RD, 0.07; 95% CI, -0.36 to 0.50; data from 3 studies) or bacteriological success (24/30 [80%] vs 3/3 [100%]; P = .99; and RD, -0.18; 95% CI, -0.79 to 0.42; data from 2 studies) between concordant and discordant therapy.

CONCLUSION

The initial discordant treatment with beta-lactam antibiotics was not associated with a statistically significant Increase in mortality or clinical or bacteriological failure of therapy for pneumococcal pneumonia.

[Managing lower respiratory tract infections in immunocompetent patients. Definitions, epidemiology, and diagnostic features]

Les infections respiratoires basses sont une des principales cause de mortalité dans le monde et les pneumopathies représentent en France la première cause de décès d'origine infectieuse. Trois entités nosologiques distinctes sont habituellement isolées en fonction de la localisation infectieuse : la bronchite aiguë, la pneumopathie et la bronchopneumopathie (atteignant les bronches et le parenchyme pulmonaire). En cas d'infections de l'arbre bronchique dans le cadre d'une bronchopathie chronique on parle de décompensation infectieuse de la maladie bronchique. Les deux principales difficultés diagnostiques de ces infections sont de déterminer la présence d'une participation alvéolaire au processus infectieux et de définir l'agent (ou les agents) pathogènes. Ces deux éléments vont conditionner la prise en charge thérapeutique. En dehors de l'examen physique, indispensable dans ce contexte, seule la radiographie thoracique pourra, en cas de persistance d'un doute, permettre de confirmer la présence d'une participation alvéolaire. Le diagnostic microbiologique pose la question de sa nécessité systématique et celui de sa valeur. Il n'est pas indispensable de réaliser un diagnostic microbiologique de certitude dans tous les cas. La décision de documentation doit répondre à deux impératifs : faisabilité et valeur diagnostique. La valeur d'un prélèvement dépend de son aptitude à mettre en évidence l'agent pathogène et dans certains cas de la possibilité d'en déterminer le profil de sensibilité (qui reste une indication majeure à la réalisation de ces prélèvements).

Pneumonies aiguës communautaires : analyse critique des essais cliniques

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.

Controversies in the treatment of pneumococcal community-acquired pneumonia

Community-acquired pneumonia remains an important cause of disease and death both in the developed and the developing worlds, despite the ready availability of potent antimicrobial agents to which the organisms remain susceptible. Furthermore, disease management is complicated by emerging resistance of the common pathogens to the various classes of commonly prescribed antimicrobial agents. Much recent research in the field of community-acquired pneumonia has focused attention on optimal treatment, evaluating the impact of antibiotic resistance, as well as of antimicrobial choices, on the outcome of these infections. In addition, efforts have been directed towards finding adjunctive therapies to antibiotics that may improve the prognosis of these patients. This article reviews some of these research areas, highlighting controversies that still exist with regard to final recommendations, and in particular with regard to infections with Streptococcus pneumoniae, the most common bacterial cause of community-acquired pneumonia.

Procalcitonin Guidance of Antibiotic Therapy in Community-acquired Pneumonia

RATIONALE

In patients with community-acquired pneumonia, guidelines recommend antibiotic treatment for 7 to 21 d. Procalcitonin is elevated in bacterial infections, and its dynamics have prognostic implications.

OBJECTIVE

To assess procalcitonin guidance for the initiation and duration of antibiotic therapy in community-acquired pneumonia.

METHODS

In a randomized intervention trial, 302 consecutive patients with suspected community-acquired pneumonia were included. Data were assessed at baseline, after 4, 6, and 8 d, and after 6 wk. The control group (n = 151) received antibiotics according to usual practice. In the procalcitonin group (n = 151), antibiotic treatment was based on serum procalcitonin concentrations as follows: strongly discouraged, less than 0.1 microg/L; discouraged, less than 0.25 microg/L; encouraged, greater than 0.25 microg/L; strongly encouraged, greater than 0.5 microg/L. The primary endpoint was antibiotic use; secondary endpoints were measures of clinical, laboratory, and radiographic outcome.

RESULTS

At baseline, both groups were similar regarding clinical, laboratory, and microbiology characteristics, and Pneumonia Severity Index. Procalcitonin guidance reduced total antibiotic exposure (relative risk, 0.52; 95% confidence interval, 0.48-0.55; p < 0.001), antibiotic prescriptions on admission (85 vs. 99%; p < 0.001), and antibiotic treatment duration (median, 5 vs. 12 d; p < 0.001) compared with patients treated according to guidelines. After adjustment for Pneumonia Severity Index, the hazard ratio of antibiotic discontinuation was higher in the procalcitonin group than in the control group (3.2; 95% confidence interval, 2.5 to 4.2). Outcome was similar in both groups, with an overall success rate of 83%.

CONCLUSIONS

Procalcitonin guidance substantially reduces antibiotic use in community-acquired pneumonia. These findings may have important clinical and public health implications.

Efficacy/safety of amoxicillin/clavulanate in adults with bacterial rhinosinusitis

PURPOSE

Acute bacterial rhinosinusitis (ABRS) is a common and uncomfortable condition, frequently caused by Streptococcus pneumoniae or Haemophilus influenzae. Antibacterial resistance among these and other common respiratory pathogens is now widespread and of concern. Pharmacokinetically enhanced amoxicillin/clavulanate 2000/125 mg was developed to be effective against the common respiratory pathogens, including many resistant strains.

MATERIALS AND METHODS

This open-label, noncomparative study assessed the bacteriologic and clinical efficacy of amoxicillin/clavulanate 2000/125 mg in adult patients with ABRS. Requirements for study entry included a clinical diagnosis of ABRS supported by radiologic findings. In addition, sinus puncture for bacteriologic assessment was required at study entry.

RESULTS

Overall, bacteriologic success (eradication or clinical evidence of eradication) at the follow-up visit (days 17-28) was achieved in 87.8% (722/822) of patients with 1 or more pathogen isolated at screening, in 93.2% (246/264) of patients with S pneumoniae, in 96.7% (29/30) of those with penicillin-resistant S pneumoniae (penicillin minimum inhibitory concentrations >or=2 microg/mL), and in 88.7% (110/124) of patients with beta-lactamase-positive pathogens. Bacteriologic success was achieved against 6 of 7 S pneumoniae isolates with amoxicillin/clavulanic acid minimum inhibitory concentrations of 4/2 microg/mL or higher.

CONCLUSIONS

Amoxicillin/clavulanate 2000/125 mg was generally well tolerated. This new amoxicillin/clavulanate formulation provides a suitable option for empiric therapy for ABRS in adults.

Efficacy and safety of twice-daily pharmacokinetically enhanced amoxicillin/clavulanate (2000/125 mg) in the treatment of adults with community-acquired pneumonia in a country with a high prevalence of penicillin-resistant Streptococcus pneumoniae

OBJECTIVES

This randomized, double-blind, non-inferiority trial evaluated the efficacy and safety of pharmacokinetically enhanced amoxicillin/clavulanate 2000/125 mg twice daily versus amoxicillin/clavulanate 875/125 mg three times daily, both given orally for 7 or 10 days, in the treatment of adults with community-acquired pneumonia in Spain, a country with a high prevalence of penicillin-resistant Streptococcus pneumoniae.

PATIENTS AND METHODS

Following 2:1 randomization, 566 patients (intent-to-treat population) received either amoxicillin/clavulanate 2000/125 mg (n = 374) or amoxicillin/clavulanate 875/125 mg (n = 192).

RESULTS

Among the patients who did not deviate from the protocol (clinical per-protocol population), clinical success at day 21-28 post-therapy (test of cure; primary efficacy endpoint) was 92.4% (266/288) for amoxicillin/clavulanate 2000/125 mg and 91.2% (135/148) for amoxicillin/clavulanate 875/125 mg (treatment difference, 1.1; 95% confidence interval, -4.4, 6.6). Bacteriological success at test of cure in the bacteriology per-protocol population was 90.8% (79/87) with amoxicillin/clavulanate 2000/125 mg and 86.0% (43/50) with amoxicillin/clavulanate 875/125 mg (treatment difference 4.8; 95% confidence interval, -6.6, 16.2). At test of cure, amoxicillin/clavulanate 2000/125 mg was clinically and bacteriologically effective against 7/7 penicillin-resistant Streptococcus pneumoniae (MIC > or = 2 mg/L) isolates (including three amoxicillin non-susceptible strains) and amoxicillin/clavulanate 875/125 mg against 5/5 isolates (including one amoxicillin non-susceptible strain).

CONCLUSIONS

Both treatment regimens were well tolerated. Amoxicillin/clavulanate 2000/125 mg was at least as effective clinically and as safe as amoxicillin/clavulanate 875/125 mg in the treatment of community-acquired pneumonia in adults in a country with a high prevalence of penicillin-resistant S. pneumoniae and has a more convenient twice daily posology.

Penicillins for Treatment of Pneumococcal Pneumonia: Does In Vitro Resistance Really Matter?

BACKGROUND

The rate of in vitro bacterial resistance to antimicrobial agents is escalating among pathogens that cause the most serious respiratory tract infections. Many reports published during the past few years suggest that this has direct clinical implications. In particular, resistance of Streptococcus pneumoniae to beta-lactam antibiotic therapy has assumed a prominent role in the evolution of guidelines for the initial treatment of respiratory tract infection.

METHODS

I conducted a critical review of the published medical literature.

RESULTS

There is only a single report of documented microbiologic failure of parenteral penicillin-class antibiotics in the treatment of pneumococcal pneumonia in patients with or without bacteremia, whereas there are numerous well-documented reports of treatment failure with quinolone-class (n > or = 21) and macrolide-class (n > or = 33) antibiotics in the treatment of pneumococcal pneumonia.

CONCLUSION

The recommended optimal in-hospital therapy for community-acquired pneumonia should continue to be a beta-lactam antibiotic (penicillin, aminopenicillin, cefotaxime, or ceftriaxone) administered with a macrolide or a fluoroquinolone agent for adjunctive treatment of infection with potential atypical pathogens.

Management of nonsevere pneumonia in military trainees with the urinary antigen test for Streptococcus pneumoniae: an innovative approach to targeted therapy

BACKGROUND

The drug of choice for treatment of Streptococcus pneumoniae infection is generally a penicillin (including amoxicillin). Targeted therapy is, however, rarely used, because results of definitive diagnostic tests for pneumonia are not available for several days. Thus, broad-spectrum antibiotics are used for empirical treatment of pneumonia to cover both typical and atypical pathogens. Our purpose was to assess the usefulness of a strategy of targeted antimicrobial therapy based on the results of a rapid urinary antigen test for S. pneumoniae.

METHODS

Military trainees with pneumonia were prospectively assigned to 2 groups: patients with positive urinary antigen test results who were treated with amoxicillin (1000 mg 3 times per day), and patients with negative urinary antigen test results who were treated with clarithromycin (500 mg 2 times per day). The duration of therapy was 5-10 days for both groups.

RESULTS

A total of 219 evaluable patients were enrolled in the study. The most common causes of pneumonia were S. pneumoniae, Chlamydia pneumoniae, and Mycoplasma pneumoniae. Patients with positive urinary antigen test results had illness of greater severity at the time of study entry. Twenty-two percent of patients had positive urinary antigen test results (i.e., the amoxicillin group), and 78% had negative urinary antigen test results (i.e., the clarithromycin group). The clinical success rates were 94% for the clarithromycin group and 90% for the amoxicillin group (P = not significant). None of the patients who were classified as having treatment failure died. Resolution of clinical manifestations was slower for patients with pneumococcal pneumonia defined by a positive urinary antigen test result.

CONCLUSIONS

The urine antigen test allowed targeted use of a penicillin (amoxicillin) for young immunocompetent individuals with nonsevere, community-acquired pneumonia. Clarithromycin was highly effective against both S. pneumoniae pneumonia and pneumonia due to atypical pathogens.

Amoxicillin/clavulanic acid 2000mg/125mg extended release (XR): a review of its use in the treatment of respiratory tract infections in adults

Amoxicillin/clavulanic acid 2000mg/125mg extended release (Augmentin XR), referred to herein as amoxicillin/clavulanic acid XR, is a pharmacokinetically enhanced formulation designed to provide more effective therapy in adults and adolescents than conventional formulations against community-acquired respiratory tract pathogens, particularly Streptococcus pneumoniae, with reduced susceptibility to amoxicillin. Amoxicillin/clavulanic acid XR maintains plasma amoxicillin concentrations above 4 microg/mL for a mean of 49% of the dosing interval indicating that it would be highly effective against S. pneumoniae strains with minimum inhibitory concentrations (MICs) above the National Committee for Clinical Laboratory Standard's amoxicillin +/- clavulanic acid susceptibility breakpoint of < or =2 microg/mL. Amoxicillin/clavulanic acid XR is at least as effective as conventional amoxicillin/clavulanic acid formulations, levofloxacin and clarithromycin in treating community-acquired pneumonia, acute bacterial sinusitis or acute exacerbations of chronic bronchitis, and has a tolerability profile comparable to that of conventional amoxicillin/clavulanic acid formulations. While the incidence of amoxicillin- or multidrug-resistant S. pneumoniae is not currently sufficient in most regions to warrant the routine empirical use of amoxicillin/clavulanic acid XR, the drug would be extremely useful in those regions with a high incidence of resistant pathogens or in selected patients (i.e. those with S. pneumoniae isolates having amoxicillin MICs > or =2 microg/mL but < or =4 microg/mL).