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Limit Quinolone Use for Pneumonia to Outpatients With Underlying Disease.

SAN FRANCISCO -- The new, broader spectrum quinolones are valuable tools for treating community-acquired pneumonia, but they will have to be used judiciously or their value will drop, according to infectious disease experts.

The Canadian Infectious Diseases Society and Canadian Thoracic Society state in their new recommendations for treating community-acquired pneumonia (CAP) that quinolone treatment should be limited to patients who require hospitalization and to outpatients who have an underlying condition.

Dr. Lionel Mandell summarized the soon-to-be-published guidelines during a session of the annual Interscience Conference on Antimicrobial Agents and Chemotherapy sponsored by the American Society for Microbiology.

The biggest difference between these guidelines and the 1998 guidelines from the Infectious Diseases Society of America is that quinolones are not an option for outpatients who do not have an underlying disease.

"This is an attempt to stop the flood of quinolone use," said Dr. Mandell, chief of infectious diseases at McMaster University in Hamilton, Ont.

The quinolones "offer a great deal, but they won't offer much if we overuse them. Many outpatients don't need a quinolone," he commented.

The Canadian recommendations tap a macrolide--azithromycin, clarithromycin, or erythromycin--as the first-line drug for otherwise healthy adults who are being treated as outpatients for CAP, Dr. Mandell explained. The second-line drug is doxycycline.

For outpatients with chronic obstructive pulmonary disease but no structural lung disease and no antibiotic or oral steroid use in the past 3 months, the first choice is a macrolide, either azithromycin or clarithromycin; erythromycin is not an option here. The second-line drug is again doxycycline, according to the Canadian guidelines.

For outpatients with chronic pulmonary disease plus structural lung disease or recent antibiotic or steroid use, a quinolone is recommended as the top choice. The second-line regimen is a second-generation cephalosporin, such as cefuroxime, plus a macrolide if needed, or amoxicillin-clavulanic acid plus a macrolide if needed.

For patients with CAP in a nursing home, the first-line treatment is a quinolone or amoxicillin-clavulanic acid, with a macrolide if necessary. The second-line regimen is a second-generation cephalosporin plus a macrolide if needed, the guidelines state.

For patients who are hospitalized in the ward with CAP, a quinolone is again the drug of choice. For patients who need intensive care, intravenous therapy with a third-generation cephalosporin, macrolide, or quinolone is necessary, Dr. Mandell said.

Which Quinolone to Use for Pneumonia?

Right now, the choice of an extended-spectrum quino1one is easy: levofloxacin. The availability of its main rival, trovafloxacin, has been severely restricted since reports of hepatotoxicity have occurred.

But two expanded-spectrum quinolones--gatifloxacin and moxifloxacin--were highlighted in several reports at the meeting and should be approved soon. Both have expanded activity against Streptococcus pneumoniae and may therefore have an advantage over levofloxacin for treating community-acquired pneumonia, said Dr. Mandell.

There should be no hepatotoxicity with gatifloxacin because it is excreted primarily by the kidneys, commented Dr. William A. Craig, who is professor of medicine at the University of Wisconsin in Madison.

But moxifloxacin is excreted, at least in part via the liver. Its safety will have to be confirmed as it is used in larger numbers of patients, he added.

Antibiotics for Community-Acquired Pneumonia [*]

Hospitalized Patients



Intensive care

intravenous treatment with a third-generation cephalosporin, macrolide, or quinolone


* First-line drug: azithromycin, clarithromycin, or erythromycin

* Second-line drug: doxycycline


* First-line drug: azithromycin or clarithromycin

* Second-line drug: doxycycline

With COPD and recent antibiotic or steroid use

* First-line drug: quinolone

* Second-line drug: second-generation cephalosporin or amoxicillin-clavulanic acid, plus a macrolide if needed

Nursing Home Patients

* First-line drug: quinolone or amoxicillin-clavulanic acid, plus a macrolide if needed

* Second-line drug: second-generation cephalosporin, plus a macrolide if needed

(*.) Based on Canadian Infectious Diseases Society recommendations.

Source: Dr. Lionel Mandell
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Publication:Family Practice News
Date:Nov 1, 1999
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