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Bacterial Infections
Table 3: Guideline Indications on Leading Pathogens and Table 4: Suggested Drug Dosing for Antimicrobials Inserted
Suggested Antimicrobials for Inpatients with Severe in Recent European and North American Guidelines for
Community-acquired Pneumonia; Also Reported Is the Community-acquired Pneunomia Management
Strength of the Recommendations
29,30
Antimicrobial Class Drug Dose
Prevailing Pathogens ERS/ESCMID 2005 ATS/IDSA Indications Beta-lactams
Indications (strength (strength of recommendation) Penicillin derivatives Amoxicillin Oral 1g every 8h
of recommendation) Amoxicillin/clavulanate Oral 2g every 12h, IV 2.2g every 8h
S. pneumoniae Non-antipseudomonal Cefotaxime Ampicillin/sulbactam IV/IM 1.5g every 8h
L. pneumophila cephalosporin III ceftriaxone Piperacillin/tazobactam IV 4.5g every 8h
S. aureus +macrolide
#
(weak) or ampicillin/sulbactam Cephalosporins (oral) Cefuroxime axetil Oral 500mg every 8–12h
H. influenzae non-antipseudomonal plus either azithromycin Cefpodoxime Oral 200mg every 12h
Enteric Gram- cephalosporin III or a fluoroquinolone# (strong) (parenteral) Cefotaxime IV/IM 1–2g every 8–12h
negative bacilli + a fluoroquinolone
#
(weak) Ceftazidime IV 2g every 8h
Risk factors for Anti-pseudomonal Antipneumococcal, Ceftriaxone IV/IM 1–2g once daily
Pseudomonas cephalosporin or antipseudomonal β-lactam Cefepime IV 2g every 12h
aeruginosa Acylureidopenicillin/ (piperacillin–tazobactam, Carbapenems Imipenem/cilastatin IV/IM 500mg – 1g every 8h
β-lactamase inhibitor or cefepime, imipenem, or Meropenem IV 1g every 8h
Carbapenem + meropenem) plus either Macrolides Azithromycin Oral/IV 500mg once daily
ciprofloxacin (weak) ciprofloxacin or levofloxacin Clarithromycin Oral/IV 500mg every 12h
(750mg dose) (moderate) or Erythromycin Oral 500mg – 1g every 6h
the above β-lactam plus Fluoroquinolones Ciprofloxacin Oral 500–750mg every 12h
an aminoglycoside and IV 400mg every 8–12h
azithromycin (moderate) Levofloxacin Oral/IV 500mg every 12–24h or
If methicillin-resistant The above plus vancomycin, The above + ancomycin Moxifloxacin IV 750mg once daily
S. aureus is an issue teicoplanin + rifampin, linezolid or linezolid (moderate) Oral/IV 400mg once daily
Aminoglycosides Amikacin IM/IV 15mg/kg once daily
Gentamicin IM/IV 5mg/kg once daily
Conversely, in combating severe respiratory infections caused by Gram-
Tobramicin IM/IV 5mg/kg once daily
negative bacilli (e.g. P. aeruginosa), AUC
0–24
/MIC ratios of 100–125 are
Glycopeptides Linezolid Oral/IV 600mg every 12h
appropriate for bacterial eradication and favourable clinical outcomes.
23
Teicoplanin IV/IM 6mg
.
kg
-1
every 12h 3 times
and then every 24h
Principles in Antibiotic Treatment of
Vancomycin IV 7.5–15mg
.
kg
-1
Community-acquired Pneumonia
every 6–12h or continuous infusion
Recent European
24
and North American
25
guidelines provide a framework
Tetracyclines Doxicycline Oral/IV 200mg once daily
for the rational use of antibiotics in the treatment of CAP. Recognised issues
IM = intramuscular; IV = intravenous.
include timeliness of treatment and choice of antimicrobial agent based on
the considerations presented in the above sections of this article. Timely microbiological data do not indicate clinically relevant bacterial
administration of antimicrobial therapy is important for hospitalised CAP resistance against these agents (see Table 1).
24
Newer macrolides such
patients. In a retrospective analysis of 14,000 Medicare hospitalisations for as azithromycin, roxithromycin or clarithromycin are indicated as
CAP, initial antibiotic administration within eight hours after arrival at the alternatives in countries with low pneumococcal macrolide resistance
hospital was associated with statistically significantly lower mortality.
26
A and in cases of intolerance to the above agents. When there are
more recent retrospective analysis of 113,000 Medicare hospitalisations clinically relevant bacterial resistance rates against all first-choice agents,
associated initiation of antimicrobial therapy within four hours after arrival or major intolerance issues, treatment with levofloxacin or moxifloxacin
with improved outcomes.
27
In contrast, prospective trials have failed to may be considered. Fluroquinolones are not recommended as first
demonstrate survival benefits deriving from antibiotic administration within choice because of concerns regarding resistance development in the
four to eight hours after arrival at hospital in CAP,
28,29
although there may community. Oral cephalosporins are indicated as not having a clear
be advantages in reducing the length of hospital stay.
30,31
Currently, added value.
guidelines do not suggest a specific time-point within which patients
hospitalised for CAP should receive initial antibiotic treatment, but rather Inpatients
indicate that first antimicrobial administration should be given in the Recommended treatment for non-severe hospitalised patients is based on
emergency department.
25
The recommended treatment options proposed the use of a β-lactam – either a penicillin derivative (penicillin G, amoxicillin
by the two latest international guidelines regarding CAP
24,25
will be or amoxicillin/clavulanate) or a cephalosporin (non-antipseudomonal
discussed in some detail, followed by an analysis of differing and second- or third-generation agent) (see Table 2). Addition of a macrolide
overlapping considerations between the guidelines. is suggested only in patients at increased risk or in more severe
pneumonia. This indication is based on the authors’ interpretation of the
European Respiratory Society/European Society of Clinical ongoing dispute regarding the benefits associated with combining a
Microbiology and Infectious Diseases Guidelines macrolide with β-lactam treatment, which have been demonstrated in
some
32,33
but not all studies.
34,35
It is still unclear whether the supposed
Outpatients benefits of the addition of a macrolide are due to coverage of atypical
Due to proven efficacy, vast experience and low costs, tetracycline and organisms (L. pneumophila, M. pneumoniae and C. pneumoniae) or other
amoxicillin are presented as first-choice antibiotics, provided that local as yet not fully elucidated (possibly immunomodulatory) effects.
104 EUROPEAN INFECTIOUS DISEASE
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