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New guidelines for the treatment of adult patients with community-acquired pneumonia

In the latest issue of Clinical Infectious Diseases, the American Society of Infectious Diseases (IDSA) published new guidelines for the treatment of immunocompetent adult patients with community-acquired pneumonia (CAP).

These guidelines are an updated version of the IDSA guidelines published in 1998 and 2000. They were prepared under the supervision of Lionel A. Mandell, McMaster University, Hamilton, Ontario, Canada, with contributions from leading American experts (John G. Bartlett, Johns Hopkins University School of Medicine, Baltimore; Scott F. Dowell, the Centers for Disease Control and Prevention, Atlanta, GA; Thomas M. File, Jr., Summa Health System, Akron, OH; and Daniel M. Musher, VA Medical Center, Houston, TX).

A distinctive feature of the new IDSA recommendations is a more detailed and balanced presentation of the key issues in the management of patients with community-acquired pneumonia, including new diagnostic and treatment approaches, the empirical choice of drugs to start treatment. Unlike previous recommendations, which provided for a fairly wide range of antibacterial drugs (ABP) for the treatment of community-acquired pneumonia, including fluoroquinolones, the new version of the recommendations proposes a more rigorous approach to the choice of ABP taking into account the individual characteristics of patients and their stratification according to two main criteria - prior ABP administration and concomitant pathology.

According to IDSA President Joseph R. Dalovisio and IDSA N. O'Grady, head of the Standards and Practices Development Committee of IDSA, the expert committee working on the news project recommendations is extremely concerned about the excessive and irrational use of fluoroquinolones, which could lead to the loss of the clinical value of this drug. drug groups over the next 5-10 years. Since the publication of previous recommendations in 2000, a number of fluoroquinolones have been withdrawn from the market due to serious safety profile problems with the drugs. In addition, the increasing resistance of microorganisms to this class of drugs is worrying.

The new guidelines suggest a more "rigorous" approach to prescribing fluoroquinolones in community-acquired pneumonia. At the same time, the appointment of macrolide antibiotics (erythromycin, azithromycin, clarithromycin) as monotherapy is considered to be adequate therapy in ambulatory patients without concomitant pathology who have not received systemic antibacterial drugs in the last 3 months.

In the presence of concomitant diseases (COPD, diabetes mellitus, chronic renal failure, chronic heart failure, malignant neoplasm), modern macrolides (azithromycin, clarithromycin) are preferred if the patient has not received antibiotic therapy and respiratory quinolones (moxifloxacin , gatifloxacin or levofcia) modern macrolides with β-lactams (amoxicillin, amoxicillin / clavulanate in high doses, cefpodoxime, cefprosil, cefuroxime) - if during the previous 3 months the patient has received systemic antibiotics.

In case of suspected aspiration, amoxicillin / clavulanate or clindamycin is recommended; bacterial superinfection in the context of influenza - β-lactams or respiratory quinolones. In community-acquired pneumonia that occurs in residents of nursing homes, it is advisable to prescribe respiratory quinolones or a combination of amoxicillin / clavulanate with modern macrolides.

In patients hospitalized in the general ward, monotherapy with respiratory quinolones or the combination of β-lactams (cefotaxime, ceftriaxone, ampicillin / sulbactam or ertapenem) with modern macrolides is recommended.

In the event of hospitalization in an ICU, the choice of medication depends on the presence of factors predisposing to infection of P.aeruginosa and a history of allergy to β-lactam antibiotics. In the absence of risk factors for infection with P.aeruginosa, β-lactams (cefotaxime, ceftriaxone, ampicillin / sulbactam or ertapenem) are recommended in combination with modern macrolides or respiratory quinolones , and in case of allergy to β-lactam antibiotics in history - respiratory quinolones ± clindamycin. If there is a risk of P.aeruginosa infection, it is advisable to prescribe the following treatment regimens: 1) anti-Pseudomonas β-lactam (piperacillin / tazobactam, imipenem, meropenem, cefepime) + ciprofloxacin; 2) anti-pseudomonas β-lactam + aminoglycoside + respiratory quinolone or modern macrolide. For allergies to β-lactams, aztreon + levofloxacin, or aztreon + moxifloxacin or gatifloxacin ± aminoglycosides are recommended.

In addition to the new approach to the choice of antibacterial drugs, the new version of the recommendations includes sections on the characteristics of community-acquired pneumonia in the elderly and severe acute respiratory syndrome (SARS). Given the epidemiological characteristics of SARS and the possibility of rapid spread of the infection through close contact, including between medical personnel and family members, there is a need to be wary of SARS. This implies compliance with certain restrictive measures for patients suspected of having SARS or a confirmed diagnosis of SARS: 1) standard precautions (hand hygiene); 2) precautions for direct contact (use of gowns, glasses, gloves); 3) measures to limit the spread of infection by air (negative pressure in the rooms where the patients are, use of disposable respirators No. 95).

Since respiratory pathogens are considered a potential source of bioterrorism, the recommendation also includes a section on various microorganisms that cause severe lung damage and, when used as an aerosol, can be potent biological weapons that affect thousands of people. These microorganisms include Bacillus anthracis, Franciscella tularensis and Yersinia pestis.

The main provisions of the new version of the IDSA recommendations are as follows:

Due to the constantly evolving situation of antibiotic resistance and the emergence of new data, according to the decision of the IDSA experts, the PE recommendations will be updated with a frequency of at least 1 time over several years. Recommendations will focus on modern achievements and the most pressing problems in the diagnosis and treatment of patients with community-acquired pneumonia.

In addition, in order to avoid the problems associated with the variety of recommendations for the treatment of community-acquired pneumonia and the presence of certain contradictions in the approaches to the management of this category of patients, the experts of the IDSA are currently preparing a draft joint recommendations on CAP in adult immunocompetent patients with experts from the American Thoracic Society. These recommendations are expected to be published in 2004.