A randomized study of ciprofloxacin versus ceftriaxone in the treatment of nursing home-acquired lower respiratory tract infections

OBJECTIVE: To compare the efficacy and safety of ciprofloxacin and ceftriaxone in patients with nursing home-acquired lower respiratory tract infections requiring initial hospitalization. DESIGN: Prospective, randomized trial. SETTING: Extended care nursing homes affiliated with a teaching hospital. PATIENTS: Fifty patients aged 60 years or older with normal or mildly impaired renal function admitted to the hospital for treatment of lower respiratory tract infections. INTERVENTIONS: Twenty-four patients received initial therapy with intravenous ciprofloxacin, 200 mg every 12 hours (19 patients) or 400 mg every 12 hours (5 patients) during the acute phase followed by 750 mg orally every 12 hours during the convalescence phase. Twenty-six patients received initial therapy with intravenous ceftriaxone, 2 g every 24 hours during the acute phase followed by 1 g administered intramuscularly every 24 hours during the convalescent phase. The total duration of therapy was 14 days. MAIN OUTCOME MEASUREMENTS: Successful outcome was defined as resolution or marked improvement in clinical signs and symptoms of lower respiratory tract infection upon completion of the treatment course. RESULTS: Twelve (50%) of the ciprofloxacin-treated and 14 (54%) of ceftriaxone-treated patients had successful outcomes. Recurrent oropharyngeal aspiration was the reason for treatment failure in most patients refractory to either antibiotic. Mortality during therapy was 8% in each group. From 21 satisfactory sputum specimens collected, S. pneumoniae was the most common isolate, followed by H. influenzae and other Gram-negative bacteria. Ciprofloxacin therapy was well tolerated; ceftriaxone therapy was discontinued in two patients (8%) due to adverse reactions (intramuscular pain and drug fever). CONCLUSIONS: Sequential intravenous/oral ciprofloxacin appears to be as safe and effective as sequential intravenous/intramuscular ceftriaxone. The optimal dosage of intravenous ciprofloxacin in this patient population appears to be 400 mg every 12 hours; however, additional clinical and pharmacokinetic studies with this regimen are warranted.     

Antibody treatment of lower respiratory tract infections

Antibody treatment of lower respiratory infection has a long history of success and is receiving renewed interest. A variety of polyclonal and monoclonal preparations are clinically available. Although used primarily for infection prophylaxis, these agents have limited applications in the treatment of established infections. Immune serum was the first effective treatment for pneumococcal pneumonia. Although long-supplanted by the advent of antibiotics, passive immunotherapy for pneumococcal and other infections is being revisited in an era of increasing antibiotic resistance and growing numbers of immunocompromised individuals. Limited clinical evidence supports the use of immune globulins in the treatment of pertussis and severe streptococcal infection. Bone marrow transplant recipients with lower respiratory infections caused by cytomegalovirus or respiratory syncytial virus also may benefit by adjunctive treatment with immune globulins. Additional indications for antibody treatment of respiratory infection may develop with further investigation.     

奈替米星与阿米卡星临床疗效观察

目的以阿米卡星为对照评价奈替米星治疗下呼吸道感染的临床有效性及安全性。方法共人选病例132例，可评价疗效者102例，其中试验组（奈替米星）与对照组（阿米卡星）分别为52例与50例。安全性评价人选病例113例，两组分别为56例与57例。给药方法试验组每次200mg，每日1次，对照组每次200mg，每日2次，两组疗程均为7～14天。结果试验组与对照组的临床有效率分别为84．61％与64．00％，细菌清除率分别为90．91％与66．67％，敏感菌百分率分别为93．18％与71．43％，听力下降发生率分别为1．79％与15．79％。以上结果经统计学处理两组差异有显著性。结论奈替米星为治疗下呼吸道感染的安全、有效的抗菌药物。     

Failure of a single dose of 100 mg ofloxacin in lower urinary tract infections in females

A single dose of 100 mg ofloxacin was compared with a multiple dose of cotrimoxazole in lower urinary tract infections in 137 women. The elimination rate was significantly lower in the single dose treated group of patients in spite of all strains being in vitro susceptible in this group.     

Flurithromycin ethylsuccinate in the treatment of lower respiratory tract bacterial infections

Summary Efficacy and tolerability of flurithromycin ethylsuccinate were evaluated in lower respiratory tract infections. One hundred and ten patients (38 women, 72 men; age range 18–87 years) were treates with on 375 mg tablet 12-hourly for a mean duration of 8.7 days. One hundred and five patients were evaluable for efficacy. Overall clinical cure rate was 62.9%; improvement was recorded in 19% of patients for a total satisfactory clinical response rate of 81.9%. Sputum production decreased in most patients, being absent after treatment in 47% (only one patient was negative at baseline); sputum was purulent or mucopurulent in 80% of subjects before and in 20% after treatment. Bacteriological evaluation was possible in 72 patients: pathogen eradication was achieved in 80.2% of cases. Eight patients out of 110 reported adverse reactions, mainly gastrointestinal; in one case treatment had to be discontinued. These results demonstrate that flurithromycin ethylsuccinate is safe and effective in the treatment of lower respiratory tract infections.

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Flurithromycin Ethylsuccinat in der Therapie bakterieller Infektionen der tiefen Atemwege

Zusammenfassung Die Wirksamkeit und Verträglichkeit von Flurithromycin Ethylsuccinat wurde bei Patienten mit Infektionen der tiefen Atemwege geprüft. 110 Patienten (38 Frauen, 72 Männer, im Alter von 18–87 Jahren) erhielten zweimal täglich eine Tablette Flurithromycin Ethylsuccinat zu 375 mg. Insgesamt wurden 62,9% der Patienten klinisch geheilt, 19% gebessert. Die Rate an befriedigendem klinischen Ansprechen lag somit bei 81,9%. Bei den meisten Patienten ging die Sputumproduktion zurück. Bei 47% hatte die Sputumproduktion nach Behandlungsende aufgehört (nur bei einem Patienten bestand zu Therapiebeginn keine Sputumproduktion). Purulentes oder mukopurulentes Sputum bestand vor Behandlung bei 80% und nach Behandlng bei 20% der Patienten. Bei 72 Patienten war eine bakteriologische Befundung möglich. In 80,2% der Fälle wurde der Erreger eliminiert. Bei acht der 110 behandelten Patienten traten Nebenwirkungen auf, die meist den Gastrointestinaltrakt betrafen. In einem Fall mußte die Behandlung abgebrochen werden. Diese Ergebnisse zeigen, daß Flurithromycin Ethylsuccinat ein wirksames und sicheres Medikament für die Behandlung tiefer Atemwegsinfektionen ist.

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Supported by Pierrel S. p. A.     

De-escalation in lower respiratory tract infections

PURPOSE OF REVIEW: The present article reviews recent data on the de-escalation of empirical antibiotic treatment on pneumonia, with special attention to newer strategies aimed at increasing adequacy and minimizing resistance emergence risks in ventilator-associated pneumonia. RECENT FINDINGS: A de-escalation strategy is feasible in a large proportion of patients with pneumonia, and at least two reports have associated de-escalation with a significantly better survival. Combined with other strategies, such as using biomarkers (e.g. C-reactive protein or procalcitonin), antibiotic heterogeneity, adherence to local microbiological flora, objective clinical criteria of non-response and of clinical ventilator-associated pneumonia resolution, they contribute to rationalizing and individualizing antimicrobial therapy. SUMMARY: A patient-based approach with prompt adequate empirical therapy, using broad-spectrum antibiotics based on reliable local microbiological data with streamlining as soon as microbiological data become available, allow outcomes to be improved and the emergence of resistance to be minimized.     

Biomarkers in lower respiratory tract infections

This review aims to provide physicians with an overview of the potential of biomarkers to complement existing clinical severity scores and in conjunction with clinical parameters to improve the diagnosis, risk-stratification and management of lower respiratory tract infections (LRTIs).The usefulness of biomarkers for diagnosing LRTIs is still unclear. However, the specificity of pneumonia diagnosis is high when high sensitivity C-reactive protein (CRP) and procalcitonin (PCT) are used.PCT, CRP and particularly pro-atrial natriuretic peptide (MR-proANP), pro-vasopressin (CT-proAVP) and proadrenomedullin (proADM) levels can reliably predict LRTIs mortality. These markers do not significantly improve the severity scores predictive values, confirming that biomarkers are meant to complement, rather than supersede, clinician’s judgment and validated severity scores.Biomarkers, and particularly PCT, are useful tools as antibiotic treatment duration indicators both in pneumonia and exacerbations of chronic obstructive pulmonary disease (COPD).Even if more data are required to fully appreciate the role of biomarkers in LRTIs management, there is emerging evidence that biomarkers have the potential to improve the daily clinical management of LRTIs.     

A randomized,dose comparison study of cefodizime in the treatment of lower urinary tract infections in women

Summary In a prospective randomized study, the efficacy and safety of 1 and 2 g of cefodizime administered as single intramuscular injections were compared in a total of 50 women having either complicated or uncomplicated lower urinary tract infections (LUTI). Bacteriological culture of urine and safety laboratory tests were performed before and after treatment. 18/25 patients in the 1 g cefodizime group and 22/25 in the 2 g cefodizime group showed satisfactory clinical and bacteriological response to treatment. The inadequately treated patients all had complicating factors on entry to the study (residual urine in six cases, a bladder malignancy in two, neurogenic bladder and diabetes mellitus with glucosuria in one case each). Cefodizime proved efficacious in female patients with uncomplicated LUTI, as well as in those aged over 65 years, patients having mild renal insufficiency, mild glucosuria, unsuccessful oral antibiotic pretreatment or recurrent and postoperative infections. In no case were there any systemic adverse reactions to cefodizime or clinically significant changes in laboratory tests.

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Randomisierte Dosisfindungsstudie für Cefodizim bei Frauen mit Infektionen des unteren Harntraktes

Zusammenfassung In dieser prospektiven randomisierten Studie wurden die Wirksamkeit und Verträglichkeit einer Einmaldosis von 1 oder 2 g Cefodizim i.m. bei 50 Frauen mit Infektionen der unteren Harnwege untersucht. Vor und nach Behandlung wurden ein Harnstatus mit Urinbakteriologie sowie Laboruntersuchungen durchgeführt. In der Dosisgruppe 1 g wurden 18 von 25 Patienten geheilt, in der Dosisgruppe 2 g 22 von 25. Bei allen unzureichend behandelten Patientinnen war vor Therapiebeginn ein komplizierter Harnweginfekt festgestellt worden (sechsmal Restharn, zweimal ein Blasentumor und je einmal eine neurogene Blasenentleerungsstörung und eine Glukosurie bei Diabetes mellitus). Cefodizim war bei unkomplizierten Harnwegsinfektionen, aber auch bei Patientinnen über 65 Jahre, bei gering eingeschränkter Nierenfunktion, bei antibiotischer Vorbehandlung und bei rezidivierenden oder postoperativen Infektionen wirksam. Systemische Nebenwirkungen oder klinisch relevante Laborveränderungen wurden nicht beobachtet.

     

Community-acquired lower respiratory tract infections: etiology and treatment.

The current therapy for community-acquired lower respiratory tract infections is often empiric, usually involving administration of a beta-lactam or macrolide. However, the increasing prevalence of antibiotic resistance in frequently isolated respiratory tract pathogens has complicated the antimicrobial selection process. This review will discuss the incidence of various respiratory pathogens, as well as update the clinician on the various antimicrobial alternatives available, with particular emphasis on the role of the newer fluoroquinolones in the treatment of acute exacerbations of chronic bronchitis and community-acquired pneumonia.     

Prospective study of lower respiratory tract infections in an extended-care nursing home program: potential role of oral ciprofloxacin

PURPOSE: Infections of the lower respiratory tract pose an important problem in nursing homes. Despite the magnitude of this problem, few, if any, antibiotic studies have been targeted specifically at nursing home-acquired bronchopulmonary infections. Following the establishment of a teaching Extended-Care Nursing Home Program, which facilitated the early diagnosis and therapy of bronchopulmonary infections, a comparative trial of oral ciprofloxacin and intramuscular cefamandole was initiated in elderly patients with lower respiratory tract infections. In addition to assessing the relative efficacy and safety of ciprofloxacin and cefamandole, our goals were to identify problems and pitfalls associated with conducting clinical research in this nursing home setting, evaluate selected clinical and laboratory features of lower respiratory tract infection in this patient population, and measure outcomes in all study groups. PATIENTS and METHODS: During a 20-month period, 40 patients with pneumonia and 20 patients with acute bronchitis were enrolled in this randomized study. Sixty-three patients with pneumonia who were ineligible for the randomized study were also followed prospectively. The mean age of the 111 participants (123 cases) was 80.8 years; all patients had at least one chronic medical condition. RESULTS: Although Streptococcus pneumoniae was the single most common isolate, gram-negative bacteria were cultured from 81 percent of the cases that yielded pathogens from a satisfactory sputum specimen. The in-hospital mortality rate was strikingly low (6.5 percent), and a large majority of patients in all study groups were discharged safely back to their nursing homes well within the Diagnosis-Related Group length of stay. CONCLUSION: Ciprofloxacin appeared to be as safe and effective as cefamandole in this nursing home program; however, additional studies are needed to determine its role in the treatment of elderly patients with bronchopulmonary infections.     

Treatment of lower respiratory tract infections with ceftriaxone and cefotaxime. A comparative study

The microbiological and clinico-therapeutic efficacy and safety of ceftriaxone were compared with those of cefotaxime in an open randomized trial. Fifty-four adult hospitalized patients (37 males and 17 females) suffering from either acute bronchopneumonia (19) or acute exacerbations of chronic bronchopneumonia (35) have been investigated. Four patients were withdrawn from the trial. Underlying diseases were present in 41 patients. Ceftriaxone was administered at a once-a-day dose of either 1 or 2 g (in 13 and 14 patients, respectively) and cefotaxime at a 2 g twice daily dosing regimen (27 patients), both antibiotics being given for 7-12 days. In the ceftriaxone group, 15 out of the 27 patients were cured (55%) and 9 had a favourable clinical response for a total satisfactory response rate of 88%. The causative pathogen was eliminated in 18 (66%) patients. The results obtained in the cefotaxime group did not differ significantly, but 2 patients were excluded from the study because of in vitro resistance of the causative pathogen isolated. Both drugs were well tolerated: no relevant laboratory changes were registered. The results indicate that ceftriaxone at a dosage of 2 or 1 g daily is at least as effective as cefotaxime given daily at a dosage of 4 g in the treatment of severe lower respiratory tract infections.     

A pilot study of 'Augmentin' in lower respiratory tract infections: pharmacokinetic and clinical results

Thirteen patients with a mean age of 67 years admitted to hospital with signs and symptoms of lower respiratory infections were treated with 'Augmentin' (500 mg amoxycillin + 250 mg clavulanic acid) given orally every 8 hours, for 7 days. The clinical response was 'good' in ten cases and one 'failed'. Two patients could not be assessed. Side-effects were not serious: only one patient had to stop treatment (due to diarrhoea). The pharmacokinetic results show that peak levels of amoxycillin and of clavulanic acid in the blood and in sputum are achieved at a later time in the patients studied than occurs in healthy volunteers.