(Chest. 1999;115:1S-2S.)
© 1999
American College of Chest Physicians
Treatment of Pneumonia and Its Implications for Antimicrobial Resistance*
Introduction
Jack M. Bernstein, MD and
G. Douglas Campbell, Jr., MD, FCCP
* From the Department of Veterans Affairs Medical Center and the Department
of Medicine/Veterans’ Affairs Campus (Dr. Bernstein), Wright State
University, Dayton, OH; and Louisiana State University (Dr. Campbell), School
of Medicine-Shreveport, Shreveport, LA.
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Introduction
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The
incidence of community-acquired pneumonia (CAP) in the United States is
estimated at 3.3 to 4 million cases per year.1
,2
Consequently, treatment of pneumonia drives a major portion of overall
antibiotic use. The need to begin antibiotic therapy quickly for
improved patient outcome makes initial empiric therapy for CAP a
practical necessity. The variety of possible etiologies for pneumonia,
however, makes selection of an appropriate empiric antibiotic
difficult. The temptation is to begin with a powerful broad-spectrum
drug, with the consequent danger of encouraging development of
resistance. The inexorable emergence of antibiotic-resistant pathogens
associated with overuse of particular antibiotics makes a strong
argument for choosing a scalpel over a mallet.
This collection of articles presents expert opinion on the use of
antibiotics for the treatment of pneumonia, with particular emphasis on
the role of antibiotic choice in minimizing the development of
resistance. Dr. Thomas File begins with an overview of how bacterial
antibiotic resistance is acquired and how it spreads. We then discuss
the guidelines introduced by the Infectious Disease Society of America
and by the American Thoracic Society to help the physician choose
antibiotics for CAP. Dr. David Burgess illustrates the importance of
pharmacodynamics in antibiotic selection and explains how the dosing of
antibiotics can be tailored to minimize the development of resistance.
For the ICU, where patients are 5 to 10 times more likely to
acquire infections than elsewhere in the hospital, Dr. David Weber and
colleagues suggest antibiotic use restrictions to reduce resistance
rates. One reason for the high rate of nosocomial infection in the ICU
is the extensive use of invasive equipment in critically ill patients.
Dr. David Bowton describes management approaches to avoid
ventilator-associated pneumonia and assesses the reliability and
clinical relevance of various diagnostic procedures. Dr. Richard Yates
reviews the encouraging results in several hospitals where trends
toward increasing antibiotic resistance have been reversed through
aggressive changes in antibiotic use, including reduced use of
third-generation cephalosporins, vancomycin, and imipenem, and
increased use of penicillin/ß-lactamase inhibitor combinations.
Despite the success of the pharmaceutical industry in developing new
antibiotics, emergence of new types of bacterial resistance has limited
progress in fighting infectious diseases. The usefulness of any
antibiotic will be short lived if it is used inappropriately. The
overuse of third-generation cephalosporins, for example, is noted in
several of the articles (Fig 1
).
Extended-spectrum ß-lactamase-producing Gram-negative bacteria can
result in treatment failure with third-generation cephalosporins,
leading to therapy with expensive reserve drugs such as
imipenem/cilastatin. Overuse of this agent, in turn, generates
resistance to the carbapenems as well as other ß-lactams and
jeopardizes their value in treatment of serious nosocomial infections.
Treatment failure can also result from overgrowth by pathogens that are
not covered by the initial antibiotic. For example, third-generation
cephalosporins are ineffective in enterococcal infections, and use of
vancomycin can select for vancomycin-resistant enterococci.
The downstream consequences of overusing third-generation
cephalosporins illustrate the importance of thinking about resistance
management when prescribing antibiotics. Appropriate antibiotic use can
slow the development of resistance and help obtain the maximum benefit
from the antibiotics at our disposal.
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Footnotes
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Correspondence to: Jack M. Bernstein, MD, Department of
Medicine/Veterans’ Affairs Campus, Wright State University, PO Box
927, Dayton, OH 45435; e-mail: bernstein@wsu-id.dayton.oh.us
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References
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- Foy, HM, Cooney, MK, Allan, I, et al (1979) Rates of pneumonia during influenza epidemics in Seattle, 1964 to 1975. JAMA 241,253-258[Abstract]
- . American Thoracic Society. (1993) Guidelines for the initial management of adults with community-acquired pneumonia: diagnosis, assessment of severity, and initial antimicrobial therapy. Am Rev Respir Dis 148,1418-1426[ISI][Medline]
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Introduction
References
