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Drug Update: Oral Drugs for Community-Acquired Pneumonia.

Community-acquired pneumonia (CAP) causes more hospitalizations than any other infection in the United States and is the sixth leading cause of death, according to the Centers for Disease Control and Prevention.

Because it often takes 48 hours to obtain laboratory results, CAP is usually treated empirically, with physicians relying on an educated guess about the infecting pathogen when choosing a therapy.

Treatment has become more complicated in recent years. Half of the pneumococci causing CAP may be penicillin resistant in some regions, and as many as a quarter of CAP cases may be caused by atypical pathogens such as Mycoplasma pneumoniae. Broad-spectrum quinolones have become a popular treatment option because of their wide coverage, but many worry that overuse of wide-spectrum drugs will fuel higher resistance rates.

Because so many patient and resistance factors must be considered when choosing a therapy, experts recommend following CAP treatment guidelines such as those published last year by the Infectious Diseases Society of America. All of the drugs listed, except for azithromycin and cefpodoxime, are usually used for 7-14 days, with 10 days the standard duration.

Quinolones are suspected to be a cause of arthropathy in young children and thus should never be used in pregnant or lactating women. Doxycycline causes permanent teeth staining in children and should likewise be avoided in pregnant or lactating women.

Finally, experts emphasize that only 40% of eligible whites, 25% of eligible blacks, and 20% of eligible Hispanics receive pneumococcal vaccination in any given year. Many CAP cases could be avoided by more vigilant use of preventive measures.
DRUG                          DOSAGE            COST/TREATMENT [*]
azithromycin                  500 mg day 1      $39.30 (5 days)
 (Zithromax)                  followed by 250
                              mg/day for 4 days
clarithromycin                500 mg b.i.d.     $65.20 (10 days)
 (Biaxin)                     7-14 days
erythromycin                  500 mg q.i.d.     $9.60 (10 days)
levofloxacin                  500 mg once a     $80.60 (10 days)
 (Levaquin)                   day
trovafloxacin                 200 mg once a     $71.90 (10 days)
 (Trovan)                     day
ciprofloxacin                 750 mg b.i.d.     $79.80 (10 days)
grepafloxacin                 600 mg once a     $61.80 (10 days)
 (Raxar)                      day
sparfloxacin                  400 mg day 1      $73.48 (10 days)
 (Zagam)                      followed by 200
                              mg/day for 9 days
amoxicillin                   500 mg t.i.d.     $10.80 (10 days)
doxycycline                   100 mg b.i.d.     $9.00 (10 days)
cefpodoxime                   200 mg b.i.d.     $109.48 (14 days)
trimethoprim-                 160 mg/800 mg     $12.60 (10 days)
sulfamethoxazole              t.i.d.
DRUG                                   COMMENT
azithromycin                           The most active macrolide monotherapy
                                       against Haemophilus influenzae. Long
                                       half-life and
 (Zithromax)                           concentration in immune cells of the
                                       lung allow once-a-day dosing. Five-day
                                       course may be more
                                       convenient than the 10- to 14-day
                                       course that's usually needed for all
                                       other drugs. Consider
                                       adding a [beta]-lactam to a macrolide
                                       in older patients with comorbid
                                       illness to cover gram-negative
                                       organisms, which may coexist with
                                       other pathogens.
clarithromycin                         Unlike azithromycin, requires b.i.d.
                                       dosing and longer treatment. Not
                                       approved for pneumonia due
 (Biaxin)                              to H. influenzae. Consider adding a
                                       [beta]-lactam to a macrolide in older
                                       patients with comorbid
                                       illness to cover possible gram
                                       negatives that could coexist with
                                       other pathogens.
erythromycin                           Least convenient macrolide to use but
                                       also the cheapest. Potential for more
                                       gastrointestinal upset
                                       may make it less attractive than other
                                       macrolides. Inconsistent activity
                                       against H. influenzae.
levofloxacin                           Antipneumococcal activity makes it and
                                       trovafloxacin the quinolones of choice
                                       for empiric
 (Levaquin)                            pneumonia therapy for many experts.
                                       Once-a-day dosing of most quinolones
                                       is an advantage.
trovafloxacin                          In June the Food and Drug
                                       Administration issued an advisory on
                                       the risk of liver toxicity. Can still
 (Trovan)                              be used to treat serious and
                                       life-threatening cases of CAP. Stop on
                                       signs of liver dysfunction or
                                       after a maximum of 14 days. Excellent
                                       activity against pneumococci,
                                       including penicillin-resistant
                                       strains; slightly more potent than
                                       levofloxacin; and longer half-life
                                       than levofloxacin.
ciprofloxacin                          Twice-a-day dosing and borderline
                                       activity against pneumococci have
                                       diminished use. No longer
 (Cipro)                               considered appropriate by many
grepafloxacin                          Few comparative studies with other
                                       agents. Not a drug of choice.
sparfloxacin                           Causes phototoxicity and
                                       photosensitivity. No longer marketed
                                       for pneumonia.
amoxicillin                            Effective against sensitive
                                       pneumococci but generally not
                                       preferred for empiric treatment. Does
                                       cover atypical pathogens, many H.
                                       influenzae strains, or
                                       penicillin-resistant pneumococci
                                       used in higher doses.
doxycycline                            Still recommended by many experts.
                                       Good activity against H. influenzae,

                                       atypical pathogens, and
                                       many pneumococci but not against
                                       penicillin-resistant species. May be
                                       effective monotherapy in
                                       younger, otherwise healthy patients.
cefpodoxime                            Good activity against S. pneumoniae
                                       and H. influenzae but not against
                                       atypical pathogens. Role in
 (Vantin)                              empiric therapy is very limited;
                                       basically an adjuvant therapy for
trimethoprim-                          No longer accepted as monotherapy for
                                       CAP due to low activity against
                                       atypical pathogens and
sulfamethoxazole                       rising levels of pneumococcal
(*.)Cost is based on average wholesale price in the
1999 Red Book for 100-unit package, or closest size,
of generic formulation, unless otherwise indicated.
Dr. Steven R. Mostow, professor of medicine,
University of Colorado, Denver.
Dr. Michael S. Niederman, professor of medicine,
State University of New York at Stony Brook.
Dr. Victor Yu, professor of medicine, University of Pittsburgh.
COPYRIGHT 1999 International Medical News Group
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1999 Gale, Cengage Learning. All rights reserved.

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Author:Zoler, Mitchel L.; Zwillich, Todd
Publication:Family Practice News
Date:Oct 1, 1999
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