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Outpatient treatment of CAP: evidence based findings

Outpatient treatment of CAP: evidence based findings. Dr. Aykut Çilli Akdeniz U niversity School of Medicine Dept . Of Respiratory Diseases -Antalya. Consultation : Abdi İbrahim Speaking fee : Astra Zeneca , Chiesi , Sanovel , Abdi İbrahim. Conflict of interest.

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Outpatient treatment of CAP: evidence based findings

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  1. Outpatienttreatment of CAP: evidencebasedfindings Dr. Aykut Çilli Akdeniz UniversitySchool of Medicine Dept. Of RespiratoryDiseases-Antalya

  2. Consultation: Abdi İbrahim Speakingfee: AstraZeneca, Chiesi, Sanovel, Abdi İbrahim Conflict of interest

  3. Mildcommunity-acquiredpneumonia • >75% of patientsaretreated as outpatients • Typicallyaged <65 yrs • No significiantcomorbidity • Mortality rate <1% • Empiricaltreatment is directedtowardthemostlikelypathogen

  4. Guidelinesfor CAP treatment • ATS/IDSA • Macrolideordoxycyline • Fluoroquinoloneor ß laktam + macrolide • ERS/ESCMID • Amoxicillinortetracycline • TurkishThorasicSociety • Amoxicillinormacrolide • ß laktam ± macrolide / doxycyline

  5. Azithromycin vs. cefaclor Randomized, double-blindstudy (n=119) Kinasewitz et al. Eur J ClinMicrobiolInfectDis 1991

  6. Randomizedcomparison of sparfloxacin, amoxycillin-clavulanicacidanderythromycin Double-blind, randomized, parallel group study (n=808) Lode et al. EurRespir J 1995

  7. Lode et al. EurRespir J 1995

  8. Amoxycillin vs. clarithromycin Macfarlane et al. British Journal of General Practice 1996

  9. Amoxycillin/clavulanate vs.cefuroximeaxetil Multicentre, randomize, investigator-blindedtrial Higuera et al. J AntimicrobChemother 1996

  10. Seventy-four (46%) of the 162 patients enrolled werebacteriologically evaluable. Higuera et al. J AntimicrobChemother 1996

  11. Amoxycillin vs. grepafloxacin Randomized, multicentre, double-blind, double-dummystudy Patients treatedwith grepafloxacin demonstrated a clinical response rate (76%) equivalent to thatseen with amoxycillin (74%) 127 137 O’Doherty et al. Chemotherapy 1997

  12. Roxithromycin vs. cefixime Randomized, doubleblindstudy (n=60) No. of pts (%) Salvarezza et al. J AntimicrobChemother 1998

  13. No. of pts (%) Salvarezza et al. J AntimicrobChemother 1998

  14. High-dosageamoxicillin vs. moxifloxacin Multinational, multicenter, double-blind, randomized study (n=411) Petitpretz et al. Chest 2001

  15. Petitpretz et al. Chest 2001

  16. Amoxicillin/clavulanate vs.cefditorenpivoxil Multicenter, prospective, randomized, investigator-blindedtrial (n=802) Fogarty et al. ClinTher 2002

  17. Sparfloxacin vs. clarithromycinorcefaclor Study 1 Study 2 Ramirez et al. ClinTher 1999 Donowitz et al. ClinTher 1997

  18. Moxifloxacin vs. clarithromycin International multi-centre, randomized, prospective, double-blind (n=531) Hoeffken et al. RespirMed 2001

  19. Hoeffken et al. RespirMed 2001

  20. Hoeffken et al. RespirMed 2001

  21. Telithromycin vs. high-doseamoxicillin Randomized, multicentre, double-blind (n=404). Hagberg et al. Infection 2002

  22. Hagberg et al. Infection 2002

  23. Clarithromycin vs. levofloxacin Double-blind, randomized, parallel-group, multicenter study 156 143 Gotfried et al. ClinTher 2002

  24. Gotfried et al. ClinTher 2002

  25. Clarithromycinextended-releasewithtrovafloxacin Prospective, multicenter, double-blind, double-dummystudy (n=176) Sokol WJ et al. ClinTher 2002

  26. Sokol WJ et al. ClinTher 2002

  27. Azithromycin vs. clarithromycinorlevofloxacin [I]Drehobl, Chest 2005 [II]D’Ignasio, AntimicrobAgentsChemother 2005

  28. Gemifloxacin vs. amoxicillin/clavulanicacid Randomized, multicentre, double-blind, phase III study (n=320). Leophontea et al. RespirMed 2004

  29. Leophontea et al. RespirMed 2004

  30. Cethromycin vs. clarithromycin Randomized, multicentre, double-blind, phase III noninferiority studies Study CL05-001 Study CL06-001 English et al. AntimicrobAgentsandChemother 2012

  31. Meta-analysis-1 18 trials 6749 patients Mildtomoderate CAP Mills et al. BMJ 2005

  32. Mills et al. BMJ 2005

  33. Meta-analysis-2 13 studies, 4314 outpatienttreated CAP patients Macrolides vs. fluoroquinolones Cephalosporins vs. β-lactams/ β-lactamaseinhibitors Atypicalcoveragevs. no atypical coverage Maimon et al. EurRespir J 2008

  34. Mortality in studies of outpatient-treated CAP by empirical antibacterial therapy Atypical vs. noatypicalcoverage. Macrolides vs. fluoroquinolones Maimon et al. EurRespir J 2008

  35. 3 trials • 622 outpatienttreated CAP patients • Anderson (1991) Clarithromycin vs. Erythromycin • Chien (1993) Clarithromycin vs. Erythromycin • Ramirez (1999) Clarithromycin vs. Sparfloxacin

  36. Conclusion • Evidence is lacking that antibiotics active against atypicalpathogens improve clinical outcomes in adults withmildtomoderate CAP • It’s not possibletodemonstrateanyadvantage of specificantibacterialsforoutpatienttreatment of CAP

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