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PubMed2004

Therapeutic implications of macrolide resistance in pneumococcal community-acquired lower respiratory tract infections.

Macrolide anti-bacterials are widely used for the empirical treatment of lower respiratory tract infections (RTIs) due to their activity against Streptococcus pneumoniae and other common respiratory pathogens and good safety/tolerability profile. However, the prevalence of macrolide resistance, particularly pneumococcal macrolide resistance, is increasing all around the world. The mechanisms underlying macrolide resistance include efflux pump, methylase activity and, less commonly, ribosomal mutation, which produce differing levels of resistance. Growth in macrolide resistance has been linked to the increased use of these agents, and several risk factors for the development of resistance have been identified. There are emerging data to suggest that in vitro macrolide resistance may increase the likelihood of treatment failure in patients with lower RTIs. However, at present, treatment failure is rare and randomised; intervention-based trials investigating the impact of anti-bacterial resistance on clinical outcomes are lacking. Strategies to promote appropriate use of macrolides and other anti-bacterials are needed, both to maximise therapeutic impact and to minimise the development of resistance. Furthermore, there is a need for alternative anti-bacterial agents which have high efficacy against respiratory pathogens (including resistant strains) and a low potential to induce resistance.

Community-Acquired Infections↗
PubMed1992

Secretion of ofloxacin into saliva in patients with respiratory tract infection.

The simultaneous saliva and plasma ofloxacin (OFLX) concentrations in patients with respiratory tract infection were measured by a microbiological agar-well diffusion assay following a single oral administration of an OFLX preparation. The maximum concentration (Cmax), the time to reach that peak (tmax) and the elimination half-life of OFLX derived from salivary concentration data were 5.2 +/- 0.4 mg/l, 1.9 +/- 0.4 h and 3.6 +/- 0.5 h, respectively, which were in agreement with those derived from plasma concentration data. The mean saliva-to-plasma concentration ratio (Cs/Cp) obtained after the administration of a single oral dose was 1.08 +/- 0.05. This was both time-independent and concentration-independent, and it showed a certain relationship with age. A significant correlation was obtained between plasma and saliva concentrations (r = 0.768, p less than 0.01). The coefficient of variation for the overall variability was approximately 30.0%. The present results indicate that the secretion of OFLX into saliva may be, at least, due to a passive diffusion mechanism, but a measurement of OFLX concentration in saliva as a guide to dose adjustment would be too wide at odds with plasma concentration to form the basis for a clinical decision.

Administration, Oral↗
PubMed2006

Investigations in subjects with cough following upper respiratory tract infection.

The study aimed to investigate subjects with cough following acute upper respiratory tract infection (URTI), and to compare those subjects unable to suppress cough ("non-suppressors") with those who were able to suppress cough ("suppressors"). Forty-three URTI subjects participated, 31 with cough associated with acute URTI and 12 healthy controls; 21 of the coughing subjects were "suppressors", 10 were "non-suppressors". We obtained responses to chemical and mechanical stimulation of the nasal cavity or the pharynx using both psychophysical measures and event-related potentials. The study provided the following results: (1) "non-suppressors" did not exhibit significantly different intensity ratings or event-related potentials in comparison to "suppressors" in terms of responses to intranasal irritant, mechanical, or olfactory stimuli; (2) when pharyngeal mechanical stimuli were investigated "suppressors" rated the stimuli as more intense than "non-suppressors" and controls; (3) latencies of event-related potentials to pharyngeal stimuli were longest in "non-suppressors". Keeping in mind the relatively small sample size, it appears possible to differentiate certain types of cough during uncomplicated URTI. This may help to explain interindividual differences in responsiveness to cough medication.

Adolescent↗
PubMed2006

Osteopathic physicians in the United States: antibiotic prescribing practices for patients with nonspecific upper respiratory tract infections.

OBJECTIVE: To assess factors related to prescribing antibiotics for nonspecific upper respiratory tract infections (URTIs) by office-based osteopathic physicians. METHODS: Retrospective analysis of physician office visits by patients with URTIs, using the National Ambulatory Medical Care Survey database for a 5-year period. Antibiotic prescribing was analyzed based on patient and physician characteristics. Multiple logistic regression modeling was then used to assess the independent contribution of these factors. RESULTS: Between July 1, 1997, and June 30, 2001, there were 9.6 million patient visits to osteopathic physicians for URTIs in the United States. Antibiotics were prescribed in 56.4% (5.41 million) of these visits. Adults, nonwhites, females, patients with a concurrent condition such as acute bronchitis, acute otitis media, acute pharyngitis, acute sinusitis, or asthma, and patients requiring additional medications for their symptoms were more likely to be given antibiotics. In addition, family physicians, physicians who were not owners of their practices, and those practicing in nonmetropolitan areas were more likely to prescribe antibiotics. CONCLUSIONS: Antibiotics were prescribed in more than 4.8 million (50%) patient visits for URTIs. Greater efforts are needed to address some of the factors that influence prescribing practices.

Adolescent↗
PubMed2004

Antibiotic treatment of acute respiratory tract infections in the elderly: effect of a multidimensional educational intervention.

OBJECTIVES: : To measure and improve antibiotic use for acute respiratory tract infections (ARIs) in the elderly. DESIGN: : Prospective, nonrandomized controlled trial. SETTING: : Ambulatory office practices in Denver metropolitan area (n=4 intervention practices; n=51 control practices). PARTICIPANTS: : Consecutive patients enrolled in a Medicare managed care program who were diagnosed with ARIs during baseline (winter 2000/2001) and intervention (winter 2001/2002) periods. A total of 4,270 patient visits were analyzed (including 341 patient visits in intervention practices). INTERVENTION: : Appropriate antibiotic use and antibiotic resistance educational materials were mailed to intervention practice households. Waiting and examination room posters were provided to intervention office practices. MEASUREMENTS: : Antibiotic prescription rates, based on administrative office visit and pharmacy data, for total and condition-specific ARIs. RESULTS: : There was wide variation in antibiotic prescription rates for ARIs across unique practices, ranging from 21% to 88% (median=54%). Antibiotic prescription rates varied little by patient age, sex, and underlying chronic lung disease. Prescription rates varied by diagnosis: sinusitis (69%), bronchitis (59%), pharyngitis (50%), and nonspecific upper respiratory tract infection (26%). The educational intervention was not associated with greater reduction in antibiotic prescription rates for total or condition-specific ARIs beyond a modest secular trend (P=.79). CONCLUSION: : Wide variation in antibiotic prescription rates suggests that quality improvement efforts are needed to optimize antibiotic use in the elderly. In the setting of an ongoing physician intervention, a patient education intervention had little effect. Factors other than patient expectations and demands may play a stronger role in antibiotic treatment decisions in elderly populations.

Acute Disease↗
PubMed2000

[Pharmacovigilance study of azithromycin tablets (500 mg) in the treatment of adult patients with respiratory tract infections].

Our aim was to study a new form of azithromycin (500 mg tablets) in order to evaluate the tolerability and the influence of the ingestion of food on tolerability, the efficacy and treatment compliance in a large number of patients with respiratory tract infections. We carried out an open, non-comparative, multicenter, observational and prospective pharmacovigilance study of 3223 outpatients with respiratory tract infections randomly assigned to receive a daily dose of azithromycin for three months taken either during or outside meals. Patients were evaluated during an initial visit and two later ones in order to record the adverse events and establish the clinical efficacy. The diagnostics were as follows: pharyngotonsillitis (1200), acute otitis media (394), acute bronchitis (1134), exacerbation of chronic bronchitis (436), and community-acquired pneumonia (53). The overall therapeutic efficacy was satisfactory (cure or improvement) in 96% to 97% at the second visit and in 93% to 94% in the third (pharyngotonsillitis, 93%; acute otitis media, 91%; acute bronchitis, 94%; exacerbation of chronic bronchitis, 94%; and community-acquired pneumonia, 96%). A total of 170 adverse events were reported in 141 patients (4.4%); 12 were severe yet not related to the study medication. Eighty-eight patients showed adverse events presumed to be related to azithromycin; most were in the digestive tract. No differences in tolerability were observed in relation to food intake. Treatment compliance was high (97%). The elevated clinical efficacy, adequate compliance and the excellent tolerability profile of azithromycin tablets make them a safe and effective alternative in the treatment of respiratory tract infections.

Adolescent↗
PubMed2006

Medication use for pediatric upper respiratory tract infections.

The present study monitored medication prescribing patterns to patients treated for upper respiratory tract infections (URTIs) in the pediatric outpatient department (OPD) at Central Referral Hospital (CRH), Gangtok, Sikkim. A total of 562 URTI prescriptions of children, aged 0-12 years attending pediatric OPD at CRH, Sikkim were collected by a random once-weekly survey between May 2002 and April 2003. Males numbered 284 (50.5%), and females 278 (49.5%). Most of the patients in our study were aged 2-5 years (preschool children) (44.8%). The average number of medications prescribed per encounter was 2.37; 59.2% (789) of medicines were fixed-dose combination (FDC) products and two-thirds of FDCs were respiratory medicines (521). The most commonly prescribed medicines were respiratory medicines (47% of the total medicines prescribed). Others were antimicrobials (30.7%) and analgesic-antipyretics (18.8%). Among respiratory medicines, cough and cold preparations (prescribed in 13 different FDC products in 25 brand names) were prescribed most frequently (62%) followed by nasal preparations (21%) and beta(2) adrenergic agonist inhalers (9.2%). Ninety-eight percent of nasal preparations were isotonic saline drops (129). Antihistaminics (41.8%), non-opioid antitussives (13.5%), alpha agonist oral decongestants (42.3%), expectorants (32.2%), mucolytics (18.7%), paracetamol (14.7%), and beta(2) agonists (17.2%) were common ingredients of respiratory medicine combinations. Antihistamines (2.5%) and beta(2) agonists (9.2%) were used alone. The most commonly prescribed antimicrobial was amoxicillin with clavulanate (28.4%) followed by cefadroxil (20%), cotrimoxazole (9.5%) and amoxicillin alone (9.3%). Average number of antimicrobials prescribed was 0.7 (409/562). The most commonly prescribed analgesic-antipyretic was paracetamol (81.3%) followed by combination of ibuprofen and paracetamol (12.4%) and nimesulide (5.6%). Medication selection was rational in few cases. Various anomalies were observed in various aspects of drug use in children for URTI's. The main aim of the initiative is the need for more rational medicine use in URTIs in children for improvement of clinical effectiveness, cost effectiveness and reduction of potential useless risk of side effects.

Analgesics↗
PubMed2002

Intravenous and oral antibiotics in respiratory tract infection: an international observational study of hospital practice.

BACKGROUND: Hospitalised patients with respiratory tract infections (RTI) frequently receive intravenous (i.v.) antibiotics followed by a short course of oral treatment. OBJECTIVES: To observe antibiotic use in hospitals in Germany, Spain, France, Italy and the UK and the reasons for choosing the i.v. route and switching to oral treatment. METHODS: Research pharmacists sought the opinions of physicians and senior nurses in the completion of a semi-structured questionnaire on the treatment of RTI with i.v. antibiotics. Questions focussed on antimicrobials of choice, reasons for choosing i.v., reasons for changing to oral administration, and duration of treatment. RESULTS: This study recruited 796 patients with RTI, usually pneumonia. Prescribing patterns varied widely between the five hospitals. Accepted clinical criteria were only commonly cited in Germany, Spain and the UK as reasons for choosing the i.v. route at the beginning of the study. These were more commonly cited at the time of switch, although other criteria such as improved condition, were other significant reasons. The mean duration of i.v. treatment ranged from 4 days in the UK to 10 days in Italy, where most patients received the full course of treatment by the i.v. route. Unlike the other hospitals studied, the few patients in Italy who were switched to another form of treatment were as likely to receive intramuscular as oral administration (13% and 11%, respectively). CONCLUSIONS: The practice of and reasons for prescribing i.v. antibiotics varied in the hospitals studied. Objective clinical criteria were inconsistently cited as reasons for administering i.v. antibiotics and in general these reasons were unrelated to those given for the switch from i.v. to oral administration. In order for guidelines for switching from i.v. to oral antimicrobials to be routinely employed, explicit physiological criteria need to be recorded in a routine fashion. Closer co-operation between pharmacists and physicians may help in developing and implementing guidelines at a local level.

Administration, Oral↗
PubMed1996

An analysis of decisions by European general practitioners to admit to hospital patients with lower respiratory tract infections. The European Study Group of Community Acquired Pneumonia (ESOCAP) of the European Respiratory Society.

BACKGROUND: The purpose of this study was to identify factors on which European general practitioners (GPs) base their decisions to admit to hospital patients with lower respiratory tract infections (LRTI). METHODS: A survey was carried out from December 1993 to January 1994 to identify factors that affect GPs' decisions to admit to hospital patients with LRTI by collecting data on 2056 patients from 605 GPs in France, Germany, Italy, Spain, and the UK. RESULTS: Only 93 (4.5%) of the patients included in the study were admitted to hospital. Univariate analysis showed that age > 60 years, institutionalisation of the patient, concomitant diseases, cardiac insufficiency, asthma, a diagnosis of pneumonia, and clinical signs such as chest pain, cyanosis, tachypnoea and hypotension significantly (odds ratio (OR) > 2.0, p < 0.002) influenced the decision to admit to hospital. No influence could be shown for sex, smoking habits, history of bronchiectasis or chronic bronchitis, the presence of fever, chills, myalgia, cough or purulent sputum, and the diagnoses of acute bronchitis, influenza or exacerbation of chronic bronchitis. In the multivariate analysis only the presence of chest pain (OR 2.3, 95% confidence interval (CI) 1.5 to 3.5), cyanosis (OR 4.1, 95% CI 2.4 to 7.1), dyspnoea (OR 4.9, 95% CI 3.1 to 7.9), and hypotension (OR 2.9, 95% CI 1.6 to 5.2), as well as a diagnosis of pneumonia (OR 6.6, 95% CI 4.3 to 10) (all p < 0.00001) remained as factors that significantly affected the decision to admit to hospital. CONCLUSIONS: Clinical signs of severe infection and a diagnosis of pneumonia are the main factors that induce GPs to admit patients with LRTI to hospital in Europe.

Europe↗
PubMedDate not supplied

[Serological researches in the bacterial respiratory tract infections (author's transl)].

Previous studies on the serological diagnosis of the lower respiratory tract infections caused by bacteria have been reviewed. The most significant results have been up to today obtained with the double immunodiffusion technique (Ouchterlony) for detecting different, specific and aspecific, bacterial precipitins in the serum of the patients, and with the immunoelectrophoresis which allows to distinguish specific precipitine lines from the aspecific ones. Among the other immunological methods, bacterial agglutination, passive haemagglutination, cross-over-immunoelectrophoresis, complement fixation, and immunofluorescence have been only occasionally used, but further comparative studies are needed and suggested to establish their diagnostic value. Other technical problems, as purity of antigens or cross-reactivity of antibody or antibodies level evaluation, are raised and discussed. Further improving of the serological methods would allow their routine use in clinical bacteriology as a useful tool in the assessment of pathogenicity of the bacterial species in the sputum and in the ethiological diagnosis of broncho pulmonary infections, at least of those cases in which exclusive relaying on sputum cultures could be fallacious.

Antibodies, Bacterial↗
PubMedDate not supplied

Ofloxacin in the treatment of lower respiratory tract infections: report of a prospective, comparative trial.

The subjects were 241 patients with lower respiratory tract infections treated at two medical centers in Austria; 161 of the patients were evaluated clinically and, of these, 69 were evaluated bacteriologically. The patients were randomly assigned to receive ofloxacin (n = 101) or a comparison drug (doxycycline [n = 27] or amoxicillin-clavulanate [n = 33]). The mean age of patients in the ofloxacin group was 61 years; that of patients in the comparison groups was 64 years. The mean duration of treatment was nine days; most patients received the study drug intravenously for three days and then orally for four to seven days. In most patients, the doses were 200 mg of ofloxacin twice daily; 100 mg of doxycycline twice daily; or 2,200 mg of amoxicillin-clavulanate intravenously two or three times daily, followed by 625 mg orally two to four times daily. The clinical response was rated satisfactory (all pretreatment symptoms disappeared) in 28% of the ofloxacin-treated patients and in 22% of the other two groups; improved (all except one symptom improved) in 70% and 65%, respectively; and unsatisfactory in 2% and 13%, respectively. The bacteriologic response was rated satisfactory in 59% of the 39 evaluable ofloxacin-treated patients and in 50% of the 30 patients in the other two groups. Most of the unsatisfactory responses were associated with persistent strains of Streptococcus pneumoniae. Transient side effects of mild to moderate severity were noted in nine of the 101 ofloxacin-treated patients and in seven of the 60 patients in the other two groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Administration, Oral↗
PubMed1990

[Treatment results using cefixime for bacterial respiratory tract infections].

In a prospective open clinical trial 20 patients with the diagnosis bacterial respiratory tract infection and underlying chronic obstructive lung disease were treated for 13 to 17 days with 200 mg cefixime b. i. d. 14 of 16 evaluable patients were treated successfully. In one patient the clinical symptoms remained unchanged and in another patient cefixime treatment failed. Ten of the 16 evaluable patients showed a positive baseline culture. In nine of these patients the initially isolated pathogens could be eliminated. In one patient, in whom cefixime therapy failed, change of pathogens was noticed after the end of treatment. Four of the 20 patients treated with cefixime reported side effects (gastritis, three; fungal dermatitis, one). In the patient with fungal dermatitis cefixime therapy was stopped.

Adult↗
PubMed2006

Clinical prediction tool to identify patients with Pseudomonas aeruginosa respiratory tract infections at greatest risk for multidrug resistance.

Despite the increasing prevalence of multiple-drug-resistant (MDR) Pseudomonas aeruginosa, the factors predictive of MDR have not been extensively explored. We sought to examine factors predictive of MDR among patients with P. aeruginosa respiratory tract infections and to develop a tool to estimate the probability of MDR among such high-risk patients. This was a single-site, case-control study of patients with P. aeruginosa respiratory tract infections. Multiple-drug resistance was defined as resistance to four or more antipseudomonal antimicrobial classes. Clinical data on demographics, antibiotic history, and microbiology were collected. Classification and regression tree analysis (CART) was used to identify the duration of antibiotic exposure associated with MDR P. aeruginosa. Log-binomial regression was used to model the probability of MDR P. aeruginosa. Among 351 P. aeruginosa-infected patients, the proportion of MDR P. aeruginosa was 35%. A significant relationship between prior antibiotic exposure and MDR P. aeruginosa was found for all of the antipseudomonal antibiotics studied, but the duration of prior exposure associated with MDR varied between antibiotic classes; the shortest prior exposure duration was observed for carbapenems and fluoroquinolones, and the longest duration was noted for cefepime and piperacillin-tazobactam. Within the final model, the predicted MDR P. aeruginosa likelihood was most dependent upon length of hospital stay, prior culture sample collection, and number of CART-derived prior antibiotic exposures. A history of a prolonged hospital stay and exposure to antipseudomonal antibiotics predicts multidrug resistance among patients with P. aeruginosa respiratory tract infections at our institution. Identifying these risk factors enabled us to develop a prediction tool to assess the risk of resistance and thus guide empirical antibiotic therapy.

Adult↗
PubMed1998

Diagnosis of lower respiratory tract infections: what we have and what would be nice.

STUDY OBJECTIVES: To review the various methods used to diagnose lower respiratory tract infections. DESIGN: Review of literature with appropriate references to various techniques proposed to diagnose pneumonia. INTERVENTION: Compare and contrast different proposed approaches to diagnose pneumonia. RESULTS: Bronchoscopic techniques appear more clear cut for certain nonbacterial pathogens. Their role in immunocompromised patients is more clear cut, while in the nonimmunocompromised patient, invasive diagnostic techniques probably provide a higher certainty of the final diagnosis of the patient. Recent interest has focused on nonbronchoscopic techniques for the mechanically ventilated patient. None of these techniques has been demonstrated to change clinical outcome. CONCLUSIONS: Diagnosis of lower respiratory tract infection has to be tailored for the individual patient. Decision about which procedure to do is influenced by the patient's underlying immune status, level of illness, and response to empiric therapy.

Bronchoalveolar Lavage↗
PubMed1999

Susceptibility of Streptococcus pneumoniae isolated from the respiratory tract of hospitalized children with respiratory tract infections.

The most frequent nasopharyngeal carriers of Streptococcus pneumoniae are young children. Frequent use of antimicrobial therapy in children facilitates the selection of penicillin-resistant strains in this population. These strains, especially if highly resistant, may cause serious therapeutic problems. Aim of the study was to monitor penicillin- and multidrug-resistant S. pneumoniae strains in hospitalized children with respiratory tract infections. Hospitalized children up to five years were examined for S. pneumoniae presence in their upper respiratory tract. Susceptibility to penicillin, erythromycin, trimethoprim/sulfamethoxazole, tetracycline, and chloramphenicol was determined by the disk-diffusion method. The minimal inhibitory concentrations (MIC) of penicillin, erythromycin and trimethoprim/sulfamethoxazole were measured by the E-test. S. pneumoniae strain was isolated from 60 (34.7%) out of 173 microbiologically examined children; 2 different strains were isolated in 9 cases. Nine strains (13.0%) were penicillin resistant with MICs ranging from 1.5 to 8 mg/L, and 17 strains (24.6%) had intermediate susceptibility. Seventeen (24.6%) strains were erythromycin resistant (MIC > or = 1 mg/L). Eighteen strains (26.1%) were resistant and 7 strains (10.1%) were intermediately susceptible to trimethoprim/sulfamethoxazole. Ten strains (14.5%) were not susceptible to tetracycline, and 11 (15.9%) to chloramphenicol. Non-susceptibility (resistance or intermediate susceptibility) to the tested antimicrobials was more prevalent in penicillin-nonsusceptible strains. The current level of S. pneumoniae resistant to antimicrobial drugs in children with respiratory tract infections in the hospital department monitored in our study do not cause problems in the choice of antibacterial therapy. Penicillins still can remain the drug of choice in cases when typical bacterial causing agents of respiratory tract infections are suspected. (Tab. 3, Fig. 2, Ref. 31.)

Child, Preschool↗
PubMed2005

A prospective study comparing human metapneumovirus with other respiratory viruses in adults with hematologic malignancies and respiratory tract infections.

Human metapneumovirus (hMPV) is a recently described paramyxovirus associated with upper and lower respiratory-tract infection (URI and LRI, respectively). We conducted a prospective study of URI and LRI in adults with hematologic malignancies during a 4-year period. We retrospectively tested samples by reverse-transcription polymerase chain reaction for hMPV and analyzed clinical data. Twenty-two (9%) of 251 episodes of respiratory infection tested positive for hMPV. Sixteen (73%) of the illnesses occurred in hematopoietic stem-cell transplant recipients. Nine patients with hMPV developed LRI; 3 of these patients died. hMPV is a common cause of respiratory infections in adults with hematologic malignancies, with associated morbidity and mortality.

Adult↗
PubMed1994

[Treatment of upper respiratory tract infections with broncho-vaxom++: a therapeutic alternative to chemotherapy?].

Studies were performed on 21 industry-products sellers suffering to recurrent infections of upper respiratory tract. Immunostimulating treatment was performed using Broncho-vaxom administered during 6 months. Drug was applied by 10 consecutive days every month, 1 tablet at the morning on empty stomach (before breakfast). During immunotherapy the decrease in work-absences and diminution of some pathological symptoms were noted. No additional chemotherapeutics were taken during Broncho-vaxom. Although the efficacy of immunostimulatory therapy with Broncho-vaxom is not certainly proved, treatment with this drug seems to present be an alternative for chemotherapeutics in recurrent infections of upper respiratory tract. That treatment is probably like the psychotherapy.

Adjuvants, Immunologic↗