Journal of Antimicrobial Chemotherapy (2002) 49, 31-40
© 2002 The British Society for Antimicrobial Chemotherapy
Review |
Antibiotic therapy of community respiratory tract infections: strategies for optimal outcomes and minimized resistance emergence
a School of Biomedical Sciences, St Andrews University, St Andrews; i Department of Medical Microbiology, City Hospital NHS Trust, Birmingham, UK; b Department of Microbiology, Hospital Ramon y Cajal, Madrid; e Department of Medicine, Hospital de Mutua de Terrassa, Barcelona, Spain; c Department of Infectious Diseases, Uppsala University, Uppsala, Sweden; d Summa Health System, Akron, Ohio; f Department of International Health, The Rollins School of Public Health, Emory University, Atlanta, Georgia, USA; g Department of Microbiology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada; h Unit of Infectious Diseases, Chaim Sheba Medical Center, Tel-Hashomer, Israel
Widespread, increasing antibiotic resistance amongst the major respiratory pathogens has compromised traditional therapy of the major infective respiratory syndromes, including bacterial pneumonia and acute exacerbations of chronic bronchitis. Guidelines for antibiotic prescribing dating from the 1980s to 1990s, which attempted to address such problems, were commonly too prescriptive and difficult to apply, and took little account of end-user practice or locally prevalent resistance levels. Further confusion was caused by conflicting recommendations emanating from differing specialty groups. The evidence that such guidelines benefited either clinical outcomes or treatment costs has been disputed. They have probably had little effect on resistance emergence. We report the recommendations of an independent, multi-national, inter-disciplinary group, which met to identify principles underlying prescribing and guideline formulation in an age of increasing bacterial resistance. Unnecessary prescribing was recognized as the major factor in influencing resistance and costs. Antibiotic therapy must be limited to syndromes in which bacterial infection is the predominant cause and should attempt maximal reduction in bacterial load, with the ultimate aim of bacterial eradication. It should be appropriate in type and context of local resistance prevalence, and optimal in dosage for the pathogen(s) involved. Prescribing should be based on pharmacodynamic principles that predict efficacy, bacterial eradication and prevention of resistance emergence. Pharmacoeconomic analyses confirm that bacteriologically more effective antibiotics can reduce overall management costs, particularly with respect to consequential morbidity and hospital admission. Application of these principles should positively benefit therapeutic outcomes, resistance avoidance and management costs and will more accurately guide antibiotic choices by both individuals and formulary/guideline committees.
* Correspondence address. 6 Gilchrist Row, St Andrews, Fife KY16 8XU, UK. Tel: +44-133-447-6049; Fax: +44-133-447-6637; E-mail: Peterball1{at}aol.com
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