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Nassau County Medical Center East Meadow, NY State University of New York at Stony Brook Stony Brook, NY
Correspondence to: Arsad A. Karcic, MD, Department of Cardiology, Nassau County Medical Center, 2201 Hempstead Turnpike, East Meadow, NY 11554; e-mail: arsad{at}aol.com
To the Editor:
We read with interest the recent article by Harwell and Brown (February 2000),1 which reviewed drug resistance of Streptococcus pneumoniae. However, little attention was given to the efficacy of ciprofloxacin against the pneumococcus. The indications and usage of ciprofloxacin in the treatment of lower respiratory tract infections (LRTI) caused by streptococcal pneumonia have remained controversial.
We reviewed 18 large clinical studies, including our own,2 3 4 and we analyzed the results of ciprofloxacin in the treatment of LRTI. From these 18 studies, we derived a total cumulative number of streptococcal LRTI treated with ciprofloxacin, which numbered 204 patients. Based on analysis of the results in these documented patients,2 we conclude that >90% of the 204 patients with streptococcal pneumonia LRTI treated with ciprofloxacin were reported cured.
There were isolated reports of treatment failures in this group, particularly in a single study by Davies et al.5 In that study, of the 26 patients with pneumococcal acute exacerbation of chronic bronchitis, only 9 improved and the remaining 17 were clinical failures. The bacterial eradication rate was only 56%. It is possible that this study was flawed because two lots of medications were used and there were four different treatment regimens. We agree that ciprofloxacin and other floroquinolones are not the first choice of treatment in patients with community-acquired LRTI who have no comorbidities. By contrast, the practical results of worldwide experience have demonstrated that ciprofloxacin works well and remains one of the treatment choices for patients with LRTI and comorbidities like diabetes, COPD, alcoholism, or nursing home-acquired LRTI, who often have polymicrobial infections with S pneumoniae as one of the pathogens.
References
Baystate Medical Center Springfield, MA
Correspondence to: Richard B. Brown, MD, FCCP, Chief, Infectious Disease Division, Baystate Medical Center, 759 Chestnut St, Springfield, MA 01199-0001
To the Editor:
Drs. Karcic and Khan correctly state that the use of ciprofloxacin for S pneumoniae-associated lower respiratory infections remains controversial. We think it important to differentiate between pneumonia and acute exacerbations of chronic bronchitis. Methods for predicting flouroquinolone outcomes have recently been reviewed1 and suggest that ciprofloxacin is suboptimal for many pneumococcal infections. Additionally, as mentioned by the authors of the letter, clinical failures in documented cases of pneumococcal pneumonia have been published.2 3 This was noted and referenced in our review. Such an observation is in keeping with our experiences of several cases of this disease that have either failed to respond and/or were associated with sustained bacteremia despite use of this agent. The Infectious Disease Society, in its guidelines for the management of community-acquired pneumonia does not consider it comparable to newer quinolones, especially at historically recommended doses.4 Use of ciprofloxacin for acute exacerbation of chronic bronchitis is more difficult to judge, because of difficulties in assessing causal pathogens, as well as a different natural history of disease. In general, we believe that there should be few downsides to use of newer quinolones for management of presumed pneumococcal infections and for the documented problems with the use of the more venerable agent.
References
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