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A Survey From Major Guidelines ..in the treatment of CAP & bronchitis. Prepared by: Magdy El-Shafei Pharm B Group Product Manager M edical U nion P harmaceuticals. M.U.P. For the memory of a great Egyptian person in industry, Medical practice and Manhood.. Prof./ Zakareya Gad.

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A survey from major guidelines in the treatment of cap bronchitis

A Survey From Major Guidelines..in the treatment of CAP & bronchitis

Prepared by:

Magdy El-Shafei

Pharm B

Group Product Manager

Medical Union Pharmaceuticals

M.U.P.


For the memory of a great Egyptian person in industry, Medical practice and Manhood..Prof./ Zakareya Gad

Honorarium


Objective Medical practice and Manhood..

To discuss the recommendations

outlined by major guidelines

For Bronchitis and CAP

Infectious Diseases Society of America

American Thoracic Society

The Canadian guidelines for the

management of AECB,

With a particular focus on what M.U.P.

Offers for the best of our patients, Doctors and medical practice.


In AECB(ABECB) Medical practice and Manhood..

Controversial role of antibiotics

  • FEV1 > 50%

  • Exacerbations =OR> 4 /Yr.

  • Heart diseases

  • Use of Oxygen

  • Antibiotics in the last 3 mo.


How the antibiotics Are chosen for AECB Medical practice and Manhood..

Contribute -With M. Ctarrahlalis- to

30-50% of bronchitis

10-15%

  • Evidence-based practice

    • Best outcome for patients

    • Best use of resource

    • Least resistance

    • Least cost

    • Restricts idiosyncratic behaviour

Staph. aureus

Strept. Pneumonia

Klebsiella Pneumonia

Haemophylus influenzae

>5 to

15%

Mycoplasma Pneumonia

Chlamydia Pneumonia

Legionella Pneumophila


In Pneumonia Medical practice and Manhood..

70% of the cases

1% Co-morbidities, Elderly

31.8 %

61.0 %

Strept. Pneumonia

Staph. aureus

35.7 %

Mortality

Klebsiella Pneumonia

Haemophylus influenzae

P. aeruginosa

Probably the most common cause of

community-acquired pneumonia

14.7 %

Mycoplasma Pneumonia

Chlamydia Pneumonia

Legionella Pneumophila


Antibiotics differences Medical practice and Manhood..

G+

Ampicillin

Amoxicillin

Strept. Pneumonia

Staph. aureus

G-

Klebsiella Pneumonia

Haemophylus influenzae

P. aeruginosa

Atypical

Mycoplasma Pneumonia

Chlamydia Pneumonia

Legionella Pneumophila

Clinical treatment failure


Antibiotics differences Medical practice and Manhood..

Macrolides

azithromycin

Clarithromycin

(spiramycin)

G+

Strept. Pneumonia

Staph. aureus

G-

Klebsiella Pneumonia

Haemophylus influenzae

P. aeruginosa

Atypical

Mycoplasma Pneumonia

Chlamydia Pneumonia

Legionella Pneumophila


Antibiotics differences Medical practice and Manhood..

3rd generation

cephalosporins

G+

Strept. Pneumonia

Staph. aureus

G-

As penicillin resistance rates increase

the rates and degrees of cephalosporin

resistance increase

Klebsiella Pneumonia

Haemophylus influenzae

P. aeruginosa

Atypical

Mycoplasma Pneumonia

Chlamydia Pneumonia

Legionella Pneumophila


Recent Studies done In Kasr El Aini Hospitals: 2009 – 2010

E.coli and Klebsiella producing cephalosporinase (ESBL) reached 75% in one study and 90% in another study*

*Prof Dr. Maha Gaafar IC Dept. ElQuasr el Einy univ. hosp 2010


Antibiotics differences 2010

G+

FQ

Ciproxacin

Strept. Pneumonia

Staph. aureus

G-

Klebsiella Pneumonia

Haemophylus influenzae

P. aeruginosa

Atypical

Mycoplasma Pneumonia

Chlamydia Pneumonia

Legionella Pneumophila


Antibiotics differences 2010

G+

FQ

Moxifloxacin

levofloxacin

Strept. Pneumonia

Staph. aureus

G-

Klebsiella Pneumonia

Haemophylus influenzae

P. aeruginosa

Atypical

Mycoplasma Pneumonia

Chlamydia Pneumonia

Legionella Pneumophila


2010 11 surfing across major guidelines
2010 -11 Surfing across major guidelines 2010

In cases of acute exacerbations of chronic bronchitis (AECB) and community-acquired pneumonia (CAP), recent guidelines suggest:

using fluoroquinolone (moxifloxacin – levofloxacin) antibiotics as first-line therapy.

This suggestion is based on level I evidence from several trials (clinical and microbial superiority of these agents).

Fluoroquinolones (moxifloxacin – levofloxacin) shorten hospital stay, reduce recurrences, and lower costs.

Resistance is still very low.

M. Balter – CFP 2002 & 2010


Canadian guidelines recommendations for the treatment of aecb

2002 2010

2011

Canadian guidelines recommendations for the treatment of AECB

If symtoms persist >10 D 

second- or third-generation cephalosporin

second-generation macrolide

Aminopenicllin

second- or third-gen.

cephalosporin

2nd gen. macrolideCiprofloxacin

Moxifloxacin- levofloxacin

penicillin + B-la

ctamase inhibitor

(Amox. – Clav)

Or (AMPICILLIN/SULBACTAM)

MoXacin

LEVANIC

UNICTAM +

Ciprofloxacin

Consider infusion


Initial empiric therapy for suspected bacterial community-acquired pneumonia (CAP) in immunocompetent adults.

LAST UPDATES: I D S A G U I D E L I N E S

SPIREX

Out patients

MoXacin

LEVANIC

UNICTAM +

Inpatients

UNICTAM +

MoXacin

LEVANIC


A study was designed to test whether community-acquired pneumonia (CAP) in immunocompetent adults.cephalosporin resistance could be reversed by withdrawing these agents. The hospital-wide cephalosporin class restriction resulted in a 44% reduction in ceftazadine-resistant Klebsiella infection and colonization.

COULD CEPHALOSPRINS resistance

BE REVERSED??

UNICTAM

3 Gram

Richard R. Yates Chest 1999


COULD CEPHALOSPRINS resistance community-acquired pneumonia (CAP) in immunocompetent adults.

BE REVERSED??

Rahal; JAMA, October, 1999


Managing aecb cap in today s guidelines
Managing community-acquired pneumonia (CAP) in immunocompetent adults.AECB & CAPIn today`s guidelines

CDC

IDSA

Mayo Clinic

Respiratory quinolones

3rd generation

(levofloxacin)

4th generation

(Moxifloxacin)

Alone or plus Amp./sulbactam

Combination penicillins

B- lactamase irreversible

Inhibitors

Like

Ampicillin/sulbactam

Amoxicillin/ clavlanic

(in CAP:Plus a macrolide)


Moxifloxacin structure activity relationship
Moxifloxacin structure activity relationship community-acquired pneumonia (CAP) in immunocompetent adults.

8

O

H3C

  • Higher gram-positive activity

  • Minimizes efflux (S. pneumoniae, S. aureus)

OH

O

Mode of action that minimizes micro resistance

F

4

5

O

3

6

2

H

7

N

1

N

NH

H

A greater binding

Affinity to the topoisomerase enzyme

  • Minimizes development of resistance

  • Enhances anaerobic activity

Petersen et al 1996 Domagala, JM 1994


Moxifloxacin community-acquired pneumonia (CAP) in immunocompetent adults.

Bactericidal in

RECORD TIME

1000 000 CFU

TO

1000 CFU

Eradication in 3hrs.

WIEDEMANN, Poster P0773, ECCMID Berlin 1999


Modern 4 community-acquired pneumonia (CAP) in immunocompetent adults.th Generation F.Quinolone

WithGreater antimicrobial power onG +ve bacteria

Moxifloxacininhibits about 90%of strept. strains, while

ciprofloxacin

only inhibits 42%.

International Journal of Antimicrobial Agents 20 (2002) 196/200


MO community-acquired pneumonia (CAP) in immunocompetent adults.RDERN: 4th Generation F.Quinolone

5times higher concentrations

over ciprofloxacin

In

Alveolar Macrophages

Data on File

*Mean ± SD measured 3H after dosing with 400 mg Andrews, et al.

JAC 40:573-577, 1997

**Measured 2 and 4H after dosing with 500 mg ciprofloxacin


Tissue Penetration community-acquired pneumonia (CAP) in immunocompetent adults.

MoxifloxacinHigh Respiratory Tissue Penetration

100

100

(mg/l)

MIC90

10

1

0.12 S.pneumoniae,

M.Catarrhalis

0.1

0.06 H.influenzae

0.01

Bronchial

Mucosa

Epithelial Lining

Fluid(ELF)

Alveolar

Macrophage

Respiratory tissue concentration after one single p.o dose

Andrews J et al.38th ICAAC, 1998;San Diego, A29


Moxifloxacin clinical success
moxifloxacin community-acquired pneumonia (CAP) in immunocompetent adults.Clinical Success


CMAJ community-acquired pneumonia (CAP) in immunocompetent adults.. 2008 March

comparisons of effectiveness and safety between fluoroquinolones and β-lactam antibiotics. indicates a statistically significant difference favours fluoroquinolone therapy;.


In aecb
In AECB community-acquired pneumonia (CAP) in immunocompetent adults.

A single-arm analysis, comparing the efficacy of moxifloxacin with ciprofloxacin in patients with acute exacerbation of chronic bronchitis (AECB)

Adapted from ref. 1

1.Mittmann N, Jivarj F, Wong A, Yoon A. Oral fluoroquinolones in the treatment of pneumonia, bronchitis and sinusitis. Can J Infect Dis. 2002; 13 (5): 293-300.


Aecb cont d
AECB ( Cont’d) community-acquired pneumonia (CAP) in immunocompetent adults.

A randomized, non-blinded, multinational, multicentre study comparing the efficacy of moxifloxacin with amoxicillin/clavulanate in 512 evaluable patients with clear signs of AECB.

Adapted from ref. 2

2.Schaberg T, Ballin I, Huchon G, et al. A multinational, multicentre, non-blinded, randomized study of moxifloxacin oral tablets compared with co-amoxiclav oral tablets in the treatment of acute exacerbation of chronic bronchitis. J Int Med Res 2001;

29 (4): 314-28.


  • Fast community-acquired pneumonia (CAP) in immunocompetent adults.Eradication of Respiratory pathogens.

  • Quick relief of symptoms.

  • Rapid and Complete clinical cure.

  • Rare bacterial resistance.

  • Minimal Risk of Drug/food Interaction.

  • No Dose adjustment in elderly , renal or hepatic patients.


Empirical Antimicrobial Therapy for Community-Acquired Pneumonia

In Immunocompetent Adults

‡Levofloxacin, gatifloxacin, moxifloxacin.§Critically ill patients in areas with significant rates of high-level pneumococcal resistance and a

suggestive sputum Gram stain should receive vancomycin or a newer quinolone pending

microbiologic diagnosis.¶ampicillin-sulbactam orPiperacillin-tazobactam.

¶Cefpodoxime, cefuroxime, high-dose amoxicillin, amoxicillin-clavulanate, or

parenteral ceftriaxone followed by oral cefpodoxime.

**Cefotaxime, ceftriaxone, ampicillin-sulbactam, or high-dose ampicillin


Be sure to cure in the time of big challenge rtis

What MUP offers Pneumonia

Be sure to cure in the time ofBIG CHALLENGERTIs

  • Quality

  • Scientific credibility

  • Price

  • Best outcome for patients

  • Best use of resource

  • Least resistance

  • Least cost

  • Restricts idiosyncratic


UNICTAM Pneumonia

What MUP offers

  • Quality

  • Scientific credibility

  • Price

Ampicillin/sulbactam

Saving Cephalosporins abuse

  • Best outcome for patients

  • Best use of resources

  • Least resistance

  • Least cost

  • Restricts idiosyncratic

Prof/ Maha Gaafar IC Dept. ElQuasr el Einy univ. hosp 2010


From cleveland to baltimore to cairo
From Cleveland to Baltimore to Cairo Pneumonia

Few years ago with Prof. Dr Awad Tag ElDin

The Egyptian Society of Chest & Tuberculosis

For what the martyrs died for

better, free & dignity Egypt


  • FEV1 > 50% Pneumonia

  • Exacerbations =OR> 4 /Yr.

  • Heart diseases

  • Use of Oxygen

  • Antibiotics in the last 3 mo.

One

Or

More

None

  • Did not

  • improve

  • Group 1

  • 2nd G Macrolide

  • 2nd or 3rd G cephalosporins

  • TMO-SMX

  • Doxycyclene

  • Group II

  • FQ

  • B-lactam/Blactamase

  • Ampicillin/sulbactam

  • Group III

  • Anbulatory patient

  • Hospitalized patient:

  • Consider Ps. Aeroginosae

  • Ciprofloxacin infusion

worsen

Improved

Improved

  • FQ

  • Moxacin - Levanic

  • Did not

  • improve

Can Resp J 2003


Cap ids a ats treatment guidelines

Empiric Treatment – Outpatient Pneumonia:

No confounding factors:

macrolide (azithromycin 500mg x 1 day then 250mg Qday or clarithromycin 500mg po Q12hrs or clarithro-ER 1000mg Qday)

or

doxycycline 100mg Q12hrs

CAP:IDSA-ATS Treatment Guidelines


CAP: PneumoniaIDSA-ATS Treatment Guidelines

  • Empiric Treatment – Outpatient:

    • Confounding factors present:

      respiratory quinolone(levofloxacin 750mg Qday, moxifloxacin 400mg Qday)

      or

      beta-lactam (amoxicillin 1g Q8hrs, amox-clav-ER 2gm Q12hrs, cefpodoxime 200mg Q12hrs, cefdinir 300mg Q12hrs, etc)+ macrolide

      or

      beta-lactam + doxycycline


Cap idsa ats treatment guidelines

Empiric Treatment – Hospitalized, non-ICU: Pneumonia

Beta-lactam (ceftriaxone, cefotaxime, ampicillin/sulbactam, or ertapenem) + macrolide or doxycycline

or

Respiratory quinolone alone

(levofloxacin, moxifloxacin, gemifloxacin)

CAP:IDSA-ATS Treatment Guidelines


Cap idsa ats treatment guidelines1

Empiric Treatment – Pneumonia

Hospitalized, ICU:

Beta-lactam (ceftriaxone, cefotaxime, or ampicillin/sulbactam) + macrolide or respiratory quinolone

PCN-allergic = resp quinolone + aztreonam

CAP:IDSA-ATS Treatment Guidelines


Fluoroquinolones for Respiratory Infections Pneumonia

Comparison of Recent Guidelines for Empiric Initial Therapy of CAP*

Williams J. Jr.

  • * ± = with or without; PCN = penicillin.


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