• Community-acquired pneumonia

    October 14, 2014

    Community-acquired pneumonia (CAP) is a common infectious disease of the lungs that occurs with significant morbidity and mortality.

    In Europe and America about 4 million cases of CAP lead to 1 million hospitalizations annually. Incidence of pneumonia is variable and depends on patient’s age, increasing in the age group over 60 years. All modern studies show that mortality in patients with CAP depends on the severity of the inflammatory process. The highest mortality occurs in patients with severe pneumonia treated in intensive care and requiring mechanical ventilation.

    Pneumonia is defined as an acute infection of the lung parenchyma, which occurs with:

    1.at least two of the following symptoms: fever, chills, severe coughing (with orwithout expectoration) or chronic cough with change in the color of the sputum, pleural pain, shortness of breath;

    2.auscultatory evidence of pneumonia (crepitation or late inspiratory crackles on restricted area, bronchial breathing);

    3.new infiltrative changes in the X-ray of the chest, for which there is no other explanation (pulmonary edema or infarction).

    Depending on the causative bacteria, pneumonias are divided into typical and atypical. The most common agents are bacteria which grow outside the host cell. Extracellular bacteria are Pnevmokokokite, Haemophilus and Moraxella and the more rare – Klebsiella, Coli. They cause the typical pneumonia, which in our country accounts for about 75% of cases.

    The most common cause of pneumonia in our country is Streptococcus pneumoniae. In our country, this microorganism is characterized by a not very high level of penicillin resistance and a tendency towards a reduction in recent years. This fact is due largely to the improvement of the antibiotic strategy for the treatment of CAP in our country.

    Haemophilus influenzae is the second most common cause of typical pneumonia, but is the most common cause of acute exacerbation of chronic bronchitis. In infants and elderly patients substantial part of pneumonia is caused by S. aureus. In recent years, a reduction of methicillin resistance of staphylococci is observed.

    Atypical community-acquired pneumonias represent a diagnostic and therapeutic challenge. They are about 15 to 25% of the community-acquired infections in the lower respiratory tract. Agents of atypical CAP are microorganisms that are difficult to cultivate.

    Legionellosis is evidenced by microbiological detection of the antigen in the urine of the patient, or by genetic, culture and serologic methods

    Treatment of CAP

    Even in hospital settings, using all diagnostic methods, the etiologic pathogen is evidenced in no more than 40-50 % of pneumonia. For this reason, the initial treatment is almost always empirical. The empirical approach to the prescription of antibiotic is based on the probability of a particular pathogen to cause disease in a particular patient. The decision on the selection of antimicrobial agent depends on many factors such as patient age, severity of condition, concomitant diseases, immune suppression, venue of treatment (outpatient or inpatient), characterization of the sensitivity of microorganisms in the geographical area and others. The conditions to be met by an empirical antibiotic treatment are the widest possible spectrum of activity, rapid and high concentration in the bronchial tree and lungs, less adverse events and convenient administration.

    During the last decades professional organizations and associations in various countries around the world have established guidelines for the treatment of CAP in adults, in order to facilitate the physicians in the choice of strategy. The Bulgarian guidelines for the treatment of CAP are based on previously existing consensus, but are consistent with the characteristics of epidemiology, etiology and risk factors in our

    Place Severity Treatment
    Subgroup Recommended Alternative
    Outpatient All Beta – lactam and/or macrolide Levofloxacin
    Hospital Mild/moderate Penicillin ± macrolide, Beta – lactam ± macrolide,  cephalosporin ІІ – ІІІ ± macrolide Levofloxacin
    Hospital Severe cephalosporin ± macrolide ІІІ generation cephalosporin ± levofloxacin
    Hospital Severe and risk for P. aeruginosa Anti-pseudomonal cephalosporin + ciprofloxacin Acyl Ureido penicillin beta-lactamase inhibitor + ciprofloxacin or with carbapenem + ciprofloxacin

    For inpatients it is recommended to begin the antibiotic therapy immediately after the confirmation of the CAP diagnosis.
    The usual duration of antimicrobial therapy is 7-10 days. For intracellular pathogens such as Legionella spp., the treatment should be at least 14 days.
    The sequential antibiotic therapy is an important component of the antibacterial treatment of pulmonary diseases. It reduces the cost of treatment, shortens the hospitalization. When the intravenous antibiotic infusion may be replaced with an oral medicament depends on the assessment of the clinical response and the evaluation of the symptoms – cough, sputum expectoration, dyspnea, fever, and leukocytosis. Most often this term is three days from the initiation of treatment, after improvement of cough and shortness of breath, normalization of body temperature, reduction of leukocytosis, and in the presence of well-functioning gastrointestinal tract. When the causative pathogen is not identified, the antibiotic must be similar to the venous.

    Tchaikapharma High Quality Medicines provides on the Bulgarian market antibiotics with the following trade names:

    JF 491 Climox (Amoxicillin/Clavulanic acid ) 875mg/125mg x 14 tabl.

    JF 509 Lifurox (Cefuroxime) 500 mg x 10 tabl.

    JF 499 Levor (Levofloxacin) 500 mg x 10 tabl.

    JF 400 Klacar (Clarithromycin) 500 mg x 14 tabl.

    JF 515 Klacar XL (Clarithromycin) 500 mg x 7 tabl.

    The price of all these antibiotics is BGN 14.99.