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Oral Drugs for Community-Acquired Pneumonia.

Note: This is a revision of a previous Drug Update (Oct. 1, 1999, p. 20) that included an incorrect statement about the marketing of sparfloxacin (Zagam).

The antibiotic is in fact indicated and marketed for the treatment of community-acquired pneumonia, as well as acute bacterial exacerbations of chronic bronchitis. FAMILY PRACTICE NEWS regrets the error.

This revision of the Drug Update also incorporates the latest information about advisories and labeling changes regarding other quinolones.

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 cause arthropathy in young children and thus should never be used in preguant or lactating women. Doxycycline causes permanent teeth staining in children and likewise should be avoided in preguant or lactating women.
DRUG                          DOSAGE            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)
sparfloxacin                  400 mg day 1      $73.48 (10 days)
 (Zagam)                      followed by 200
                              mg/day for 9 days
grepafloxacin                 Not applicable    Not applicable
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 marcolide monotherapy against
 (Zithromax)                  Haemophilus influenzae. Long half-life and
                              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
 (Biaxin)                     longer treatment. Not approved for pneumonia due
                              to H. influenzae. Consider ading 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 grastrointestinal
                              upset may make it less attractive than other
                              macrolides. Inconsistent activity against H.
levofloxacin                  Antipheumococcal activity makes it the quinolone
 (Levaquin)                   of choice for empiric pneumonia therapy for many
                              experts. Once-a-day dosing of most quinolones is
                              an advantage.
trovafloxacin                 Food and Drug Administration issued an advisory
 (Trovan)                     last June on the risk of liver toxicity and
                              limited use to inpatient facilities. Can still
                              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
                              pencillin-resistant strains; slightly more
                              potent than levofloxacin; longer half-life than
ciprofloxacin                 Twice-a-day dosing and borderline activity
 (Cipro)                      against pneumococci have diminished use. No
                              longer considered appropriate by many experts.
sparfloxacin                  Causes phototoxicity and photosensitivity. Not a
 (Zagam)                      drug of choice.
grepafloxacin                 Pulled from the market because of risk of
 (Raxar)                      cardiac arrhythmias.
amoxicillin                   Effective against sensitive pneumococci but
                              generally not preferred for empiric treatment.
                              Does not cover atypical pathogens, many H.
                              inflenzae strains, or penicillin-resistant
                              pneumococci unless 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
cefpodoxime                   Good activity against S. pneumoniae and H.
 (Vantin)                     influenzae but not against atypical pathogens.
                              Role in empiric therapy is very limited;
                              basically an adjuvant therapy for macrolides.
trimethoprim-                 No longer accepted as monotherapy for CAP due to
sulfamethoxazole              low activity against atypical pathogens and
                              rising levels of pneumococcal resistance.

(*.)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.

(**.)The comments reflect the viewpoints and expertise of the following sources:

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
Article Type:Brief Article
Date:Dec 15, 1999
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