1
|
Wu M, Yang X, Tian J, Fan H, Zhang Y. Antibiotic Treatment of Pulmonary Infections: An Umbrella Review and Evidence Map. Front Pharmacol 2021; 12:680178. [PMID: 34737694 PMCID: PMC8560894 DOI: 10.3389/fphar.2021.680178] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 09/06/2021] [Indexed: 02/05/2023] Open
Abstract
Background: Considering the global burden of pulmonary infections, there is an urgent need for optimal empirical antimicrobial therapy strategies for pulmonary infections, which should rely on reliable evidence. Therefore, we aim to investigate the optimal treatment options for pulmonary infections in adults and assess the strength of that evidence. Methods: We searched PubMed, Embase, the Cochrane Library, and China Biology Medicine disc to identify systematic reviews and meta-analyses of randomized controlled trials (RCTs) focusing on antimicrobial treatments for pulmonary infections. The outcomes of the included meta-analyses should include all-cause mortality or clinical treatment success. For each meta-analysis, we estimated relative risk (RR) with 95% CI. We also created an evidence map to show the efficacy of each antimicrobial treatment strategy and the certainty of the evidence. Results: Twenty-six meta-analyses and two new RCTs were included that contained 31 types of antimicrobial therapy strategies. We found that carbapenems were related to lower mortality than other β-lactams or fluoroquinolones alone or in combination with aminoglycosides for HAP patients (RR 0.76, 95% CI: 0.58-0.99). There was no statistical difference in all-cause mortality between the other antimicrobial therapy strategies. As for clinical cure, treatment with fluoroquinolones was associated with better success versus macrolides or β-lactams alone for CAP patients in both the intention-to-treat (ITT) population (RR 1.22, 95% CI: 1.02-1.47) and clinically evaluable (CE) population (RR 1.37, 95% CI: 1.11-1.68). Treatment with carbapenems showed a better clinical cure over non-carbapenems for VAP patients (RR 1.21, 95% CI: 1.05-1.4). Adjunctive inhaled antibiotics compared with intravenous antibiotics alone showed a benefit for VAP (RR 1.2, 95% CI: 1.05-1.35). In addition, adjunctive nebulized aminoglycoside for nosocomial pneumonia was associated with a higher cure rate versus intravenous antibiotics alone in the ITT population (RR 1.28, 95% CI: 1.04-1.57), while no statistical difference in clinical cure was observed between other intervention groups. Conclusions: We cannot evaluate which antibiotic is the best choice for the treatment of pulmonary infection. Carbapenems or adjunctive inhaled antibiotics showed a reasonable choice for HAP or VAP. However, we do not find a statistical difference between most antimicrobial therapy strategies for CAP patients.
Collapse
Affiliation(s)
- Man Wu
- Department of Respiratory and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Xue Yang
- Department of Respiratory and Critical Care Medicine, Shenzhen People’s Hospital, Shenzhen, China
| | - Jinhui Tian
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Hong Fan
- Department of Respiratory and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Yonggang Zhang
- Department of Periodical Press, West China Hospital, Sichuan University, Chengdu, China
| |
Collapse
|
2
|
Adriaenssens N, Bruyndonckx R, Versporten A, Hens N, Monnet DL, Molenberghs G, Goossens H, Weist K, Coenen S. Consumption of quinolones in the community, European Union/European Economic Area, 1997-2017. J Antimicrob Chemother 2021; 76:ii37-ii44. [PMID: 34312652 PMCID: PMC8314103 DOI: 10.1093/jac/dkab176] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Objectives Data on quinolone consumption in the community were collected from 30 EU/European Economic Area (EEA) countries over two decades. This article reviews temporal trends, seasonal variation, presence of change-points and changes in the composition of main subgroups of quinolones. Methods For the period 1997–2017, data on consumption of quinolones, i.e. ATC group J01M, in the community and aggregated at the level of the active substance, were collected using the WHO ATC/DDD methodology (ATC/DDD index 2019). Consumption was expressed in DDD per 1000 inhabitants per day and in packages per 1000 inhabitants per day. Quinolone consumption was analysed by subgroups based on pharmacokinetic profile, and presented as trends, seasonal variation, presence of change-points and compositional changes. Results In 2017, quinolone consumption in the community expressed in DDD per 1000 inhabitants per day varied by a factor of 8.2 between countries with the highest (Bulgaria) and the lowest (Norway) consumption. The second-generation quinolones accounted for >50% of quinolone consumption in most countries. Quinolone consumption significantly increased up to 2001, and did not change significantly afterwards. Seasonal variation increased significantly over time. Proportional consumption of third-generation quinolones significantly increased over time relative to that of second-generation quinolones, while proportional consumption of both third- and second-generation quinolones significantly increased relative to that of first-generation quinolones. Levofloxacin and moxifloxacin represented >40% of quinolone consumption in the community in southern EU/EEA countries. Conclusions Quinolone consumption in the community is no longer increasing in the EU/EEA, but its seasonal variation continues to increase significantly as is the proportion of quinolones to treat respiratory infections.
Collapse
Affiliation(s)
- Niels Adriaenssens
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium.,Centre for General Practice, Department of Family Medicine & Population Health (FAMPOP), University of Antwerp, Antwerp, Belgium
| | - Robin Bruyndonckx
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium.,Interuniversity Institute for Biostatistics and statistical Bioinformatics (I-BIOSTAT), Data Science Institute, Hasselt University, Hasselt, Belgium
| | - Ann Versporten
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Niel Hens
- Interuniversity Institute for Biostatistics and statistical Bioinformatics (I-BIOSTAT), Data Science Institute, Hasselt University, Hasselt, Belgium.,Centre for Health Economic Research and Modelling Infectious Diseases, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Dominique L Monnet
- Disease Programmes Unit, European Centre for Disease Prevention and Control, Stockholm, Sweden
| | - Geert Molenberghs
- Interuniversity Institute for Biostatistics and statistical Bioinformatics (I-BIOSTAT), Data Science Institute, Hasselt University, Hasselt, Belgium.,Interuniversity Institute for Biostatistics and statistical Bioinformatics (I-BIOSTAT), Catholic University of Leuven, Leuven, Belgium
| | - Herman Goossens
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Klaus Weist
- Disease Programmes Unit, European Centre for Disease Prevention and Control, Stockholm, Sweden
| | - Samuel Coenen
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium.,Centre for General Practice, Department of Family Medicine & Population Health (FAMPOP), University of Antwerp, Antwerp, Belgium
| | | |
Collapse
|
3
|
Prulifloxacin Effectiveness in Moderate-to-Severe Acute Exacerbations of Chronic Bronchitis: Α Noninterventional, Multicentre, Prospective Study in Real-Life Clinical Practice-The "AIOLOS" Study. Can Respir J 2021; 2021:6620585. [PMID: 34122678 PMCID: PMC8172323 DOI: 10.1155/2021/6620585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 04/27/2021] [Accepted: 05/11/2021] [Indexed: 11/21/2022] Open
Abstract
Real-world evidence regarding the effectiveness of prulifloxacin in the treatment of acute exacerbations of chronic bronchitis (AECB) is limited. Therefore, this study aimed to assess the rates and time to symptom improvement and resolution in patients with moderate-to-severe AECB who were given prulifloxacin in the routine care in Greece. This observational, prospective study, conducted in 15 hospital-based clinics across Greece, enrolled outpatients >40 years old, with moderate-to-severe AECB, for whom the physician had decided to initiate treatment with prulifloxacin. Data were collected at prulifloxacin onset (baseline), 7–10 days after baseline, and at least 28 days after therapy completion. Between 23 November 2015 and 27 January 2018, 305 patients (males: 76.4%; mean (standard deviation) (SD) age: 69.7 (9.8) years; Anthonisen type I/II: 94.8%; chronic bronchitis duration >10 years: 24.9%) were consecutively enrolled. At baseline, >80% had increased sputum volume, cough, dyspnoea, and sputum purulence. Prulifloxacin improved symptoms in 99.7% of the patients after a mean (SD) of 5.47 (3.57) days, while symptoms fully recovered after a mean (SD) of 10.22 (5.00) days in 95.4%. The rate of adverse events related to prulifloxacin was 1.3% (serious: 0.7%). In the routine care in Greece, prulifloxacin was highly effective in moderate-to-severe AECB, while displaying a predictable safety profile.
Collapse
|
4
|
Lee MTG, Lee SH, Chang SS, Chan YL, Pang L, Hsu SM, Lee CC. Comparative Treatment Failure Rates of Respiratory Fluoroquinolones or β-Lactam + Macrolide Versus β-Lactam Alone in the Treatment for Community-Acquired Pneumonia in Adult Outpatients: An Analysis of a Nationally Representative Claims Database. Medicine (Baltimore) 2015; 94:e1662. [PMID: 26426664 PMCID: PMC4616833 DOI: 10.1097/md.0000000000001662] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
No comparative effectiveness study has been conducted for the following 3 antibiotics: respiratory fluoroquinolones, β-lactam, and β-lactam + advanced macrolide. To gain insights into the real-world clinical effectiveness of these antibiotics for community-acquired pneumonia in adult outpatients, our study investigated the treatment failure rates in 2 million representative participants from the National Health Informatics Project (NHIP) of Taiwan. A new-user cohort design was used to follow NHIP participants from January 2000 until December 2009. Treatment failure was defined by either one of the following events: a second antibiotic prescription, hospitalization due to CAP, an emergency department visit with a diagnosis of CAP, or 30-day nonaccident-related mortality. From 2006 to 2009, we identified 9256 newly diagnosed CAP outpatients, 1602 of whom were prescribed levofloxacin, 2100 were prescribed moxifloxacin, 5049 were prescribed β-lactam alone, and 505 were prescribed advanced macrolide + β-lactam. Compared with the β-lactam-based regimen, the propensity score-matched odds ratio for composite treatment failure was 0.81 (95% CI, 0.67-0.97) for moxifloxacin, 1.10 (95% CI, 0.90-1.35) for levofloxacin, and 0.95 (95% CI, 0.67-1.35) for macrolide +β-lactam. Moxifloxacin was associated with lower treatment failure rates compared with β-lactam alone, or levofloxacin in Taiwanese CAP outpatients. However, due to inherent limitations in our claims database, more randomized controlled trials are required before coming to a conclusion on which antibiotic is more effective for Taiwanese CAP outpatients. More population-based comparative effectiveness studies are also encouraged and should be considered as an integral piece of evidence in local CAP treatment guidelines.
Collapse
Affiliation(s)
- Meng-Tse Gabriel Lee
- From the Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan (M-TGL, S-HL, C-CL); Department of Family Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan (S-SC); Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan (S-SC); Department of International Business, Asia University, 500, Lioufeng Rd., Wufeng, Taichung City, Taiwan (Y-LC); Loyola University New Orleans College of Law 6363 St Charles Ave, New Orleans, LA (LP); Department of Business Administration, Tunghai University, Tunghai University, Taichung City, Taiwan (S-MH); and Department of Emergency Medicine and Department of General Medicine, National Taiwan University Hospital Yunlin Branch, Douliou, Taiwan (C-CL)
| | | | | | | | | | | | | |
Collapse
|
5
|
Liu HH. Use of the respiratory fluoroquinolones for the outpatient management of community-acquired pneumonia. Curr Ther Res Clin Exp 2014; 65:225-38. [PMID: 24764589 DOI: 10.1016/s0011-393x(04)80047-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2004] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Approximately 4 million cases of community-acquired pneumonia (CAP) occur in the United States each year, with the majority treated on an outpatient basis. The first fluoroquinolones (eg, ciprofloxacin) were used with caution for respiratory tract infections due to limited in vitro activity against common gram-positive pathogens. With the availability of levofloxacin, followed by gatifloxacin and moxifloxacin hydrochloride, which exhibited increased activity against gram-positive organisms, the fluoroquinolones have become a practical choice for the treatment of CAP. OBJECTIVE The aim of this review was to compare the respiratory fluoroquinolones in the outpatient management of CAP. METHODS We conducted a search for English-language articles (key terms: fluoroquinolone, levofloxacin, gatifloxacin, moxifloxacin, and pneumonia; years: 1996-2004). Data from published literature were reviewed regarding clinical and microbiologic efficacy and tolerability; pharmacokinetic and pharmacodynamic properties; and drug costs of levofloxacin, gatifloxacin, and moxifloxacin. RESULTS The 3 fluoroquinolones reviewed showed comparable clinical and microbiologic efficacy for the treatment of CAP. In general, the fluoroquinolones were well tolerated, although some differences have been reported, including higher rates of gastrointestinal and other adverse events for gatifloxacin and moxifloxacin. Gatifloxacin and moxifloxacin exhibited greater in vitro potency than levofloxacin against Streptococcus pneumoniae. However, levofloxacin achieved a higher serum drug concentration than the other agents, allowing similar attainment of pharmacokinetic and pharmacodynamic targets required for effective treatment. CONCLUSIONS The respiratory fluoroquinolones provided appropriate first line treatment in select patients with CAP on the basis of their microbiologic and clinical efficacy and their safety profiles.
Collapse
Affiliation(s)
- Hans H Liu
- Jefferson Medical College, Philadelphia, Pennsylvania, and Bryn Mawr Medical Specialists Association, Bryn Mawr, Pennsylvania, USA
| |
Collapse
|
6
|
Dartois N, Castaing N, Gandjini H, Cooper A. Tigecycline Versus Levofloxacin for the Treatment of Community-Acquired Pneumonia: European Experience. J Chemother 2013; 20 Suppl 1:28-35. [DOI: 10.1179/joc.2008.20.supplement-1.28] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
|
7
|
Torres A, Liapikou A. Levofloxacin for the treatment of respiratory tract infections. Expert Opin Pharmacother 2012; 13:1203-12. [PMID: 22594848 DOI: 10.1517/14656566.2012.688952] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Fluoroquinolone use has dramatically increased since the introduction of the first respiratory fluoroquinolone in the late 1990s. Levofloxacin , like other fluoquinolones, is a potent antibiotic, due to high levels of susceptibility among Gram-negative, Gram-positive (including penicillin-resistant strains of Streptococcus pneumonia) and atypical pathogens. Levofloxacin is recommended for the treatment of community-acquired pneumonia (CAP), hospital-acquired pneumonia (HAP) and in the management of acute exacerbations of chronic bronchitis (AECB). Levofloxacin demonstrates good safety, bioavailability and tissue penetration, thus maintaining adequate concentrations at the site of infection. High-dose (750 mg), short-course (5 days) therapy regimens may offer improved treatment, especially in HAP, due to higher drug concentrations, increased adherence and the potential to reduce the development of resistance. AREAS COVERED This article covers medical literature published in any language since 1990 until November 2011, on 'levofloxacin', identified using PubMed and MEDLINE. The search terms used were 'levofloxacin' and 'community acquired pneumonia', 'hospital pneumonia' or 'AECB'. EXPERT OPINION Levofloxacin is a valuable antimicrobial agent and an optimal treatment option for AECB, CAP (as a monotherapy) and HAP (as combination therapy at a high-dose regimen). Its improved bioavailability and safety profile makes the possibility of shorter hospital stays a reality.
Collapse
Affiliation(s)
- Antoni Torres
- University of Barcelona, Respiratory Department, Villarroel 170 Barcelona 08036, Spain.
| | | |
Collapse
|
8
|
Woodhead M, Blasi F, Ewig S, Garau J, Huchon G, Ieven M, Ortqvist A, Schaberg T, Torres A, van der Heijden G, Read R, Verheij TJM. Guidelines for the management of adult lower respiratory tract infections--summary. Clin Microbiol Infect 2012; 17 Suppl 6:1-24. [PMID: 21951384 DOI: 10.1111/j.1469-0691.2011.03602.x] [Citation(s) in RCA: 195] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
This document is an update of Guidelines published in 2005 and now includes scientific publications through to May 2010. It provides evidence-based recommendations for the most common management questions occurring in routine clinical practice in the management of adult patients with LRTI. Topics include management outside hospital, management inside hospital (including community-acquired pneumonia (CAP), acute exacerbations of COPD (AECOPD), acute exacerbations of bronchiectasis) and prevention. The target audience for the Guideline is thus all those whose routine practice includes the management of adult LRTI.
Collapse
Affiliation(s)
- M Woodhead
- Department of Respiratory Medicine, Manchester Royal Infirmary, Oxford Road, Manchester, UK.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
9
|
Woodhead M, Blasi F, Ewig S, Garau J, Huchon G, Ieven M, Ortqvist A, Schaberg T, Torres A, van der Heijden G, Read R, Verheij TJM. Guidelines for the management of adult lower respiratory tract infections--full version. Clin Microbiol Infect 2011; 17 Suppl 6:E1-59. [PMID: 21951385 PMCID: PMC7128977 DOI: 10.1111/j.1469-0691.2011.03672.x] [Citation(s) in RCA: 592] [Impact Index Per Article: 45.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
This document is an update of Guidelines published in 2005 and now includes scientific publications through to May 2010. It provides evidence-based recommendations for the most common management questions occurring in routine clinical practice in the management of adult patients with LRTI. Topics include management outside hospital, management inside hospital (including community-acquired pneumonia (CAP), acute exacerbations of COPD (AECOPD), acute exacerbations of bronchiectasis) and prevention. Background sections and graded evidence tables are also included. The target audience for the Guideline is thus all those whose routine practice includes the management of adult LRTI.
Collapse
Affiliation(s)
- M Woodhead
- Department of Respiratory Medicine, Manchester Royal Infirmary, Oxford Road, Manchester, UK.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Tanaseanu C, Milutinovic S, Calistru PI, Strausz J, Zolubas M, Chernyak V, Dartois N, Castaing N, Gandjini H, Cooper CA. Efficacy and safety of tigecycline versus levofloxacin for community-acquired pneumonia. BMC Pulm Med 2009; 9:44. [PMID: 19740418 PMCID: PMC2753558 DOI: 10.1186/1471-2466-9-44] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2009] [Accepted: 09/09/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tigecycline, an expanded broad-spectrum glycylcycline, exhibits in vitro activity against many common pathogens associated with community-acquired pneumonia (CAP), as well as penetration into lung tissues that suggests effectiveness in hospitalized CAP patients. The aim of the present study was to compare the efficacy and safety of intravenous (IV) tigecycline with IV levofloxacin in hospitalized adults with CAP. METHODS In this prospective, double-blind, non-inferiority phase 3 trial, eligible patients with a clinical diagnosis of CAP supported by radiographic evidence were stratified by Fine Pneumonia Severity Index and randomized to tigecycline or levofloxacin for 7-14 days of therapy. Co-primary efficacy endpoints were clinical response in the clinically evaluable (CE) and clinical modified intent-to-treat (c-mITT) populations at test-of-cure (Day 10-21 post-therapy). RESULTS Of the 428 patients who received at least one dose of study drug, 79% had CAP of mild-moderate severity according to their Fine score. Clinical cure rates for the CE population were 88.9% for tigecycline and 85.3% for levofloxacin. Corresponding c-mITT population rates were 83.7% and 81.5%, respectively. Eradication rates for Streptococcus pneumoniae were 92% for tigecycline and 89% for levofloxacin. Nausea, vomiting, and diarrhoea were the most frequently reported adverse events. Rates of premature discontinuation of study drug or study withdrawal because of any adverse event were similar for both study drugs. CONCLUSION These findings suggest that IV tigecycline is non-inferior to IV levofloxacin and is generally well-tolerated in the treatment of hospitalized adults with CAP. TRIAL REGISTRATION NCT00081575.
Collapse
|
11
|
Siempos II, Dimopoulos G, Falagas ME. Meta-analyses on the Prevention and Treatment of Respiratory Tract Infections. Infect Dis Clin North Am 2009; 23:331-53. [DOI: 10.1016/j.idc.2009.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
|
12
|
Vardakas KZ, Siempos II, Grammatikos A, Athanassa Z, Korbila IP, Falagas ME. Respiratory fluoroquinolones for the treatment of community-acquired pneumonia: a meta-analysis of randomized controlled trials. CMAJ 2008; 179:1269-77. [PMID: 19047608 PMCID: PMC2585120 DOI: 10.1503/cmaj.080358] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND We investigated whether the use of respiratory fluoroquinolones was associated with better clinical outcomes compared with the use of macrolides and beta- lactams among adults with pneumonia. METHODS We searched PubMed, Current Contents, Scopus, EMBASE, ClinicalTrials.gov and Cochrane with no language restrictions. Two reviewers independently extracted data from published trials that compared fluoroquinolones (levofloxacin, moxifloxacin, gemifloxacin) with macrolides or beta-lactams or both. A meta-analysis was performed with the clinical outcomes of mortality, treatment success and adverse outcomes. RESULTS We included 23 trials in our meta-analysis. There was no difference in mortality among patients who received fluoroquinolones or the comparator antibiotics (OR 0.85, 95% CI 0.65-1.12). Pneumonia resolved in more patients who received fluoroquinolones compared with the comparator antibiotics for the included outcomes in the intention-to-treat population (OR 1.17, 95% CI 1.00-1.36), clinically evaluable population (OR 1.26, 95% CI 1.06-1.50) and the microbiologically assessed population (OR 1.67, 95% CI 1.28-2.20). Fluoroquinolones were more effective than a combination of beta-lactam and macrolide (OR 1.39, 95% CI 1.02-1.90). They were also more effective for patients with severe pneumonia (OR 1.84, 95% CI 1.02-3.29), those who required admission to hospital (OR = 1.30, 95% CI 1.04-1.61) and those who required intravenous therapy (OR = 1.44, 15% CI 1.13-1.85). Fluoroquinolones were more effective than beta-lactam and macrolide in open-label trials (OR = 1.35, 95% CI 1.08-1.69) but not in blinded randomized controlled trials (OR = 1.13, 95% CI 0.85-1.50). INTERPRETATION Fluoroquinolones were associated with higher success of treatment for severe forms of pneumonia; however, a benefit in mortality was not evident. A randomized controlled trial that includes patients with severe pneumonia with or without bacteremia is needed.
Collapse
|
13
|
Psaty BM. Clinical trial design and selected drug safety issues for antibiotics used to treat community-acquired pneumonia. Clin Infect Dis 2008; 47 Suppl 3:S176-9. [PMID: 18986285 PMCID: PMC2587028 DOI: 10.1086/591400] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
High-quality evaluations of both efficacy and safety are essential to characterize the risk-benefit profile of antibiotics. The current US Food and Drug Administration guidelines on trial design for community-acquired pneumonia have several weaknesses, including the failure to insist on the use of double blinding and intention-to-treat analysis. A primary difficulty with noninferiority designs is that poorly conducted studies, which increase noise, are biased toward the conclusion of noninferiority even in the presence of important differences between the test drug and the control drug. Additionally, results of noninferiority trials, in the absence of a well-established anchor, may be difficult to interpret. The US Food and Drug Administration drug-evaluation process includes preclinical studies to assess toxicity and a series of clinical studies involving humans to define efficacy and to identify potential safety problems. When signals are apparent, as they were for telithromycin (liver toxicity in rats, dogs, and monkeys) or for sparfloxacin (prolongation of the QT interval in dogs), it is nonetheless essential that these signals are fully and fairly evaluated in human studies with adequate power. Risks of antibiotic use, such as prolongation of the corrected QT interval and sudden death, may be acceptable in the presence of convincing benefits for patients with severe, life-threatening infections; however, the risk-benefit profile derived from severe infections cannot necessarily be generalized to mild or self-limited infections, for which the same serious drug-associated risks are likely to exceed the benefits. Complete and proper evaluation of both safety and efficacy in specific situations is essential to define the risk-benefit profiles of all drugs, including antibiotics.
Collapse
Affiliation(s)
- Bruce M Psaty
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, Seattle, Washington, USA.
| |
Collapse
|
14
|
Leroy O, Saux P, Bédos JP, Caulin E. Comparison of Levofloxacin and Cefotaxime Combined With Ofloxacin for ICU Patients With Community-Acquired Pneumonia Who Do Not Require Vasopressors. Chest 2005; 128:172-83. [PMID: 16002932 DOI: 10.1378/chest.128.1.172] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES To evaluate the efficacy and tolerability of levofloxacin (L) as monotherapy in patients with severe community-acquired pneumonia (CAP) in comparison with therapy using a combination of cefotaxime (C) plus ofloxacin (O). DESIGN Prospective, randomized 1:1, comparative, open, parallel-group study. SETTING Multinational study with 149 sites. PATIENTS A total of 398 randomized patients who had been admitted to the ICU with severe CAP without shock, including 308 patients in a modified intent-to-treat population and 271 patients in the per-protocol (PP) population (L group, 139 patients; C + O group, 132 patients). INTERVENTIONS Therapy with levofloxacin (500 mg IV, q12h) vs therapy with a C + O combination (C, 1g IV, q8h; O, 200 mg IV, q12h) for 10 to 14 days. MEASUREMENTS AND RESULTS The main end point was the clinical efficacy at the end of treatment (ie, the test-of-cure [TOC] visit). The statistical hypothesis was the noninferiority of L therapy to C + O therapy with a 2.5% alpha risk (unilateral) and a 15% maximum set difference. At the TOC visit, a clinical success was observed in 79.1% of patients (L group) and 79.5% of patients (C + O group) in the PP population (difference, -0.4%; 95% confidence interval [CI], -10.79 to 9.97% without adjustment for simplified acute physiology score [SAPS] II at inclusion; difference, -0.3%; 95% CI, -10.13 to 9.58% with adjustment for SAPS II). A satisfactory bacteriologic response was present in 73.7% of L group patients and 77.5% of C + O group patients, including responses of 75.7% and 70.3%, respectively, in the L group and C + O group in the Streptococcus pneumoniae-documented population. In the safety analysis, 20 patients in the L group (10.3%) and 16 patients in the C + O group (8.0%) experienced at least one adverse event that was considered to be treatment-related. CONCLUSION L therapy was at least as effective as the combination therapy of C + O in the treatment of a subset of patients with CAP requiring ICU admission. This conclusion cannot be extrapolated to patients requiring mechanical ventilation or vasopressors (ie, those patients in shock).
Collapse
Affiliation(s)
- Olivier Leroy
- Service de Réanimation Médicale et Maladies Infectieuses, Hôpital G. Chatiliez, 135 rue du Président Coty, 59208 Tourcoing, France.
| | | | | | | |
Collapse
|
15
|
Yu VL, Greenberg RN, Zadeikis N, Stout JE, Khashab MM, Olson WH, Tennenberg AM. Levofloxacin Efficacy in the Treatment of Community-Acquired Legionellosis. Chest 2004; 125:2135-9. [PMID: 15189933 DOI: 10.1378/chest.125.6.2135] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Although fluoroquinolones possess excellent in vitro activity against Legionella, few large-scale clinical trials have examined their efficacy in the treatment of Legionnaires disease. Even fewer studies have applied rigorous criteria for diagnosis of community-acquired Legionnaires disease, including culture of respiratory secretions on selective media. METHODS Data from six clinical trials encompassing 1,997 total patients have been analyzed to determine the efficacy of levofloxacin (500 mg qd or 750 mg qd) in treating patients with community-acquired pneumonia (CAP) due to Legionella. RESULTS Of the 1,997 total patients with CAP from the clinical trials, 75 patients had infection with a Legionella species. Demographics showed a large portion of these patients were < 55 years of age and nonsmokers. More than 90% of mild-to-moderate and severe cases of Legionella infection resolved clinically at the posttherapy visit, 2 to 14 days after treatment termination. No deaths were reported for any patient with Legionnaires disease treated with levofloxacin during the studies. CONCLUSIONS Levofloxacin was efficacious at both 500 mg for 7 to 14 days and 750 mg for 5 days. Legionnaires disease is not associated only with smokers, the elderly, and the immunosuppressed, but also has the potential to affect a broader demographic range of the general population than previously thought.
Collapse
Affiliation(s)
- Victor L Yu
- VAMC and University of Pittsburgh, Pittsburgh, PA, USA
| | | | | | | | | | | | | |
Collapse
|
16
|
Martinez FJ. Monotherapy versus Dual Therapy for Community-Acquired Pneumonia in Hospitalized Patients. Clin Infect Dis 2004; 38 Suppl 4:S328-40. [PMID: 15127366 DOI: 10.1086/382689] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Several medical-specialty professional societies have suggested that combination therapy with a beta -lactam plus a macrolide or doxycycline or monotherapy with a "respiratory quinolone" (i.e., levofloxacin, gatifloxacin, moxifloxacin, or gemifloxacin) are optimal first-line therapy for patients hospitalized with community-acquired pneumonia. These recommendations are based predominantly on retrospective studies that suggest improved rates of morbidity and mortality and hospital length of stay among patients treated in such a fashion. Well-designed, prospective, randomized studies confirming this tenet of therapy have not been published, although numerous prospective studies have provided indirect confirmation. The biological rationale for such a differential response (i.e., favoring combination therapy or fluoroquinolone therapy) includes the immunomodulatory effects of macrolides or more-optimal treatment of primary infection or coinfection with atypical pathogens. Well-designed, prospective, randomized trials are required to best define the effectiveness of combination therapy with a beta -lactam plus macrolide or doxycycline or with a respiratory quinolone in hospitalized patients with community-acquired pneumonia.
Collapse
Affiliation(s)
- Fernando J Martinez
- Division of Pulmonary and Critical Care, University of Michigan Medical Center, Ann Arbor, Michigan 48109-0360, USA.
| |
Collapse
|
17
|
Mandell LA, Bartlett JG, Dowell SF, File TM, Musher DM, Whitney C. Update of practice guidelines for the management of community-acquired pneumonia in immunocompetent adults. Clin Infect Dis 2003; 37:1405-33. [PMID: 14614663 PMCID: PMC7199894 DOI: 10.1086/380488] [Citation(s) in RCA: 670] [Impact Index Per Article: 31.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2003] [Accepted: 10/07/2003] [Indexed: 02/04/2023] Open
|